1. Criminal justice “errors” might also be called “adverse events,” “mistakes,” “omissions,” or “non-conformities.”
  2. National Institute of Justice, “NIJ’s Sentinel Events Initiative,” June 17, 2016, https://perma.cc/DL85-RMMA.     
  3. James M. Doyle, “Learning from Error in the Criminal Justice System: Sentinel Event Reviews,” in Mending Justice: Sentinel Event Reviews (Washington, DC: U.S. Department of Justice, National Institute of Justice, 2014, NCJ 24714); James M. Doyle, “NIJ’s Sentinel Events Initiative: Looking Back to Look Forward,” National Institute of Justice Journal 273 (2014):10-14.
  4. Ibid, Doyle, “Learning from Error,” (2014). A culture of safety includes the following features as conceptualized by the Agency for Healthcare Research and Quality (AHRQ): “1) acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations, 2) a blame-free environment where individuals are able to report errors or near-misses without fear of reprimand or punishment, 3) encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems, and 4) organizational commitment of resources to address safety concerns.” See Agency for Healthcare Research and Quality Patient Safety Network, Patient Safety Primer: Safety Culture, July 2016, https://perma.cc/3RX4-FE33.
  5. New York State Justice Task Force, Recommendations Regarding Root Cause Analysis, June 2015, https://perma.cc/6C74-K698; The Quattrone Center, Using Root Cause Analysis to Instill a Culture of Self-Improvement: Program Replication Materials, April 20, 2015, https://perma.cc/M7TA-DCR9. See also Josh Hollway, “A Systems Approach to Error Reduction in Criminal Justice," Public Law and Legal Theory Research Paper Series, 14-6 (2014).
  6. Nancy Ritter, “Testing a Concept and Beyond: Can the Criminal Justice System Adopt a Nonblaming Practice?” National Institute of Justice Journal 276 (2015): 38-45.
  7. NIJ is funding Vera’s work on A Sentinel Events Approach to Addressing Suicide and Self-Harm in Jail (Grant # 2014-IJ-CX-0030); a wide range of definitions exist for “self-harm.” This report provides broad data on the problem of self-harm in correctional facilities but suggests that sentinel event reviews be reserved for those events that are particularly serious—whether because of their potential for lethality or the frequency with which they occur. See "Identify the sentinel event" under the section "Steps for conducting a root cause analysis (RCA)" for further discussion of this point.
  8. Bureau of Justice Statistics, Mortality in Local Jails and State Prisons 2000-2013—Statistical Tables (Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics, 2015, NCJ 248756); Kenneth L. Applebaum, Judith A. Savageau, Robert L. Trestman, Jeffrey L. Metzner, and Jacques Baillargeon, “A National Survey of Self-Injurious Behavior in American Prisons,” Psychiatric Service 62, no.3 (2011): 285-290. 
  9. ibid, Bureau of Justice Statistics, 2015.
  10. Christopher J. Mumola, Suicide and Homicide in State Prisons and Local Jails (Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics, 2005, NCJ 210036); ibid, Bureau of Justice Statistics, 2015; and Centers for Disease Control and Prevention, “2014, United States Suicide Injury Deaths and Rates per 100,000,” Fatal Injury Reports, National and Regional, 1999-2014, June 24, 2015, https://perma.cc/S8BJ-6Y93.
  11. Ibid, Centers for Disease Control and Prevention, 2015. The same demographic trends can be found in suicides in the community, although the rate of suicide among men in the community is four times greater than the rate of suicide among women. 
  12. Katherine Dixon-Gordon, Natalie Harrison, and Ronald Roesch, “Non Suicidal Self-Injury within Offender Populations: A Systematic Review,” International Journal of Forensic Mental Health 11 (2012): 34.
  13. The total number of acts of self-injury increased by 24 percent between 2007 and 2011. When the decline in the average daily population during this time is accounted for, this increase is 38 percent. See Daniel Selling, Angela Solimo, David Lee, Kerry Horne, Elena Panove, and Homer Venters, “Surveillance of Suicidal and Nonsuicidal Self-Injury in the New York City Jail System,” Journal of Correctional Health Care 20, no.2 (2013): 163-167.
  14. Laura Frank and Regina T.P. Aguirre, “Suicide Within United States Jails: A Qualitative Interpretive Meta-Synthesis,” Journal of Sociology and Social Welfare XL, no.3 (2013): 31-52; Doris J. James and Lauren E. Glaze, Mental Health Problems of Prison and Jail Inmates (Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics, 2006, NCJ 213600); Henry J. Steadman, Fred C. Osher, Pamela Clark Robbins, Brian Case, and Steven Samuels, “Prevalence of Serious Mental Illness Among Jail Inmates,” Psychiatric Services 60, no.6 (2009): 761-765.
  15. Abdel Halim Boudoukha, Emin Altintas, S. Rusinek, and Marc Hautekeete, “Inmates-to-Staff Assaults, PTSD and Burnout: Profiles of Risk and Vulnerability,” Journal of Interpersonal Violence 28, no.11 (2013): 2332-2350; and Heidi Hales, Mona Freeman, Amanda Edmondson, and Pamela Taylor, “Witnessing Suicide-Related Behavior in Prison: A Qualitative Study of Young Male Prisoners in England,” Crisis 35 (2014): 10-17.
  16. Thomas J. Fagan, Judith Cox, Steven J. Helfand, and Dean Aufderheide, “Self-Injurious Behavior in Correctional Settings,” Journal of Correctional Health Care 16, no.1 (2010): 48-66.
  17. Hayden P. Smith and Robert J. Kaminski, “Self-Injurious Behaviors in State Prisons: Findings from a National Survey,” Criminal Justice and Behavior 38, no.1 (2011): 26-41; and Dana D. DeHart, Hayden P. Smith, and Robert J. Kaminski, “Institutional Responses to Self-Injurious Behaviors Among Inmates,” Journal of Correctional Health Care 15 (2009): 129-141.
  18. Lindsay M. Hayes, “Reducing Inmate Suicides Through the Mortality Review Process,” Public Health Behind Bars: From Prisons to Communities (New York: Springer Science and Business Media, 2007); Lindsay M. Hayes, National Study of Jail Suicide: 20 Years Later (Washington, DC: U.S. Department of Justice, National Institute of Corrections, 2010); Lindsay M. Hayes, “National Study of Jail Suicide: 20 Years Later,” Journal of Correctional Health Care 18, no.3 (2012): 233-245; Lindsay M. Hayes, “Suicide Prevention in Correctional Facilities: Reflections and Next Steps,” International Journal of Law and Psychiatry 36 (2013):188-194; and Jeffrey L. Metzner and Lindsay M. Hayes, “Suicide Prevention in Jails and Prisons,” in Textbook of Suicide Assessment and Management (Washington, DC: American Psychiatric Association, 2012).
  19. Ibid, Hayes, 2013; and Ibid, Metzner and Hayes, 2012.
  20. National Commission on Correctional Health Care, Standards for Health Services in Jails (Chicago: National Commission on Correctional Health Care, 2014).
  21. Hayes, 2010.
  22. James M. Doyle, “Learning from Error in American Criminal Justice,” The Journal of Criminal Law & Criminology 100, no.1 (2010): 109-147. (The quote is from page 118 of the report).
  23. Hayes, 2012.
  24. For additional guidance on differentiating self-injurious behavior and suicide attempts, see Barent W. Walsh, Treating Self-Injury: A Practical Guide, 2nd edition (New York: Guilford Press, 2012). 
  25. Smith and Kaminski, 2011.
  26. Other methods that might be considered include, for example, common cause analysis or human factors analysis. For The Joint Commission’s discussion of possible methods for conducting a comprehensive systematic analysis, see The Joint Commission, Root Cause Analysis in Health Care: Tools and Techniques, 5th edition (Oakbrook, IL: The Joint Commission, 2015).  
  27. New York State Justice Task Force, 2015; The Quattrone Center, 2015.
  28. Katherine B. Percarpio, B. Vince Watts, and William B. Weeks, “The Effectiveness of Root Cause Analysis: What Does the Literature Tells Us,” The Joint Commission Journal on Quality and Patient Safety 34, no. 7 (2008): 391-398.
  29. Ibid, Percarpio, Watts, and Weeks, 2008.
  30. Surveys of health care professionals have found that a large majority of people who have conducted RCAs or participated in RCA trainings feel that RCAs improve work practices, facilitate teamwork, improve communication about patients, and result in a safer clinical culture. See Jeffrey Braithwaite, Mary Westbrook, Nadine A. Mallock, Joanne F. Travaglia, and Rick A. Iedema, “Experiences of Health Professionals Who Conducted Root Cause Analyses After Undergoing a Safety Improvement Programme,” BMJ Quality & Safety 15 (2006): 393-399; Paul Bowie, Joe Skinner, and Carl de Wet, “Training Health Care Professionals in Root Cause Analysis: A Cross-Sectional Study of Post-Training Experiences, Benefits and Attitudes,” BMC Health Services Research 13 (2013): 50.
  31. Jurisdictions involved in beta testing sentinel event reviews for NIJ suggested the following metrics as a start: 1) Were recommendations for changes in policies or procedures made? 2) Were the recommendations presented to decision-makers? 3) Did team participants value the process? 4) Were similar “potential” sentinel events averted? See National Institute of Justice, Paving the Way: Lessons Learned in Sentinel Event Reviews (Washington, DC: U.S. Department of Justice, National Institute of Justice, 2015, NCJ 249097).
  32. This section draws extensively on literature for conducting RCAs in medical settings (and, where possible, in response to incidents of suicide specifically), because the examples provided are most relevant to understanding how such a process might be carried out in response to an incident of suicide or serious self-harm in a criminal justice setting; Center for Medicare & Medicaid Services, “Guidance for Conducting Root Cause Analysis (RCA) with Performance Improvement Projects (PIP),”  https://perma.cc/J8XF-9G5U ; Center for Medicare & Medicaid Services, “How to Use the Fishbone Tool for Root Cause Analysis,” https://perma.cc/2WHB-QX6H  ; The Joint Commission, 2016; Veterans Health Administration, National Patient Safety Improvement Handbook, 2011,  https://perma.cc/8PW8-HNX6 ; Bjørn Andersen, Tom Fagerhaug, and Marti Beltz, Root Cause Analysis and improvement in the Healthcare Sector: A Step-by-step Guide (Milwaukee, WI: ASQ Quality Press, 2009); Brenda M. Ewen and Gale Bucher, “Root Cause Analysis: Responding to a Sentinel Event,” Home Healthcare Nurse 31, no. 8 (2013): 435-443; and Charles Vincent, “Understanding and Responding to Adverse Events,” The New England Journal of Medicine 348, no. 11 (2003): 1051-1056.
  33. This is a case in which an unplanned event almost, but ultimately did not, result in a serious error.
  34. Doyle, “Learning from Error,” 2010. 
  35. Andersen, Fagerhaug, and Beltz, 2009.
  36. Center for Medicare & Medicaid Services, “Guidance for Conducting Root Cause Analysis (RCA) with Performance Improvement Projects (PIP),” https://perma.cc/ZYH2-M3B5
  37. Center for Medicare & Medicaid Services, “Guidance for Conducting Root Cause Analysis (RCA) with Performance Improvement Projects (PIP),” https://perma.cc/ZYH2-M3B5; and Ewen and Bucher, 2013.
  38. Veterans Health Administration, 2011.
  39. National Institute of Justice, Paving the Way: Lessons Learned in Sentinel Event Reviews (Washington, DC: U.S. Department of Justice, National Institute of Justice, 2015, NCJ 249097).
  40. Ewen and Bucher, 2013.
  41. The question of discipline is a complex one and, to date, there may not be enough research on how to manage a potential disciplinary process in relation to the goals of a sentinel event review. However, as one participant in NIJ’s Sentinel Events Initiative Expert Roundtable noted, there are avenues outside a sentinel event review by which staff can be disciplined if necessary. See National Institute of Justice, The Sentinel Events Initiative: Proceedings from an Expert Roundtable (Washington, DC: U.S. Department of Justice, National Institute of Justice, 2013, NCJ 243586).
  42. Center for Medicare & Medicaid Services, “Guidance for Conducting Root Cause Analysis (RCA) with Performance Improvement Projects (PIP),” 4, https://perma.cc/ZYH2-M3B5.
  43. Andersen, Fagerhaug, and Beltz, 2009, 38.
  44. Ewen and Bucher, 2013, 437.
  45. Bjorn Andersen and Tom Natland Fagerhaug, ASQ Pocket Guide to Root Cause Analysis (Milwaukee, WI: ASQ Quality Press, 2006); Ibid, Ewen and Bucher, 2013, 438.
  46. Ibid, Ewen and Bucher, 2013, 438.
  47. The Joint Commission, “Sentinel Events,” 10.
  48. Center for Medicare & Medicaid Services, “Guidance for Conducting Root Cause Analysis (RCA) with Performance Improvement Projects (PIP)," https://perma.cc/ZYH2-M3B5; Ewen and Bucher, 2013; and Veterans Health Administration, 2011.
  49. Ibid, Ewen and Bucher, 2013.
  50. Dea Hughes, “Root Cause Analysis: Bridging the Gap Between Ideas and Execution,” VA National Center for Patient Safety, Topics in Patient Safety 6, no.5 (2006):1-4.
  51. Ewen and Bucher, 2013.
  52. Ibid.
  53. Center for Medicare & Medicaid Services, “Guidance for Conducting Root Cause Analysis (RCA) with Performance Improvement Projects (PIP),” https://perma.cc/ZYH2-M3B5
  54. Albert W. Wu, Angela K.M. Lipshutz, and Peter J. Pronovost, “Effectiveness and Efficiency of Root Cause Analysis in Medicine,” Journal of the American Medical Association 299, no. 6 (2008).
  55. National Institute of Justice, 2015, 12-13; Bowie, Skinner, and de Wet, 2013; Braithwait et al., 2006; and Wu, Lipshutz, and  Pronovost, 2008, 685-687.
  56. See 45 CFR §164.512 and 45 CFR §164.104.
  57. The Office for Victims of Crime in the U.S. Department of Justice has examined the question of confidentiality and has looked at demonstration projects that address and resolve confidentiality questions in its work on elder abuse review teams. See Lori A. Stiegel, Elder Abuse Fatality Review Teams: A Replication Manual (Washington, DC: American Bar Association, 2005).
  58. N.Y. Correct. Law § 47 (McKinney); 40 RCNY § 3-10.
  59. Sanchez v. State of New York, 99 N.Y.2d 247, 258 (N.Y. 2002).
  60. See Cygan v. City of New York, 165 A.D.2d 58, 67 (1st Dept. 1991). The case held that an officer’s widow could not allege that her husband’s municipal employer was negligent in the instance that he turned his gun on himself while off-duty, since the suicide was not foreseeable. The record contains no evidence that the deceased was suicidal or that his employer should have anticipated that he was such that he should not have been allowed to carry a weapon.
  61. Ibid.
  62. Estelle v. Gamble, 429 U.S. 97 (1976).
  63. Doyle, “Learning from Error,” (2014), 13.
  64. Vera has not undertaken a multi-state survey of the liability standards, and each agency should consult its own counsel in considering what its obligations are and how best to meet them.
  65. Doyle, “Learning from Error,” (2014).
"Sentinel event reviews in aviation and medication" text box 

a. National Transportation Safety Board, Aviation Accident Reports, https://perma.cc/9MQQ-39LC.

b. Jamie N. Deis, Keegan M. Smith, Michael D. Warren, Patricia G. Throop, Gerald B. Hickson, Barbara J. Joers, and Jayant K. Deshpande, “Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement,” Advances in Patient Safety: New Directions and Alternative Approaches, Vol. 2: Culture and Redesign (Rockville, MD: Agency for Healthcare Research and Quality, 2008). 

c. Lucian L. Leape, “Error in Medicine,” Journal of the American Medical Association 272, no. 23 (1994): 1851-1857; Institute of Medicine, To Err is Human: Building a Safer Health System, edited by Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson (Washington, DC: Institute of Medicine, 1999).

d. The Joint Commission, Sentinel Event Policy and Procedures, January 16, 2016, https://perma.cc/AZY2-TJCG. The Joint Commission requires that accredited organizations define a “patient safety event” for its own purposes. The definition must encompass events defined by The Joint Commission but can also include incidents in which no harm or only minor harm occurs. Theoretically, in a correctional setting, this could mean that “patient safety event” is broadly defined to include incidents of serious self-harm as well as suicides. See The Joint Commission, “Sentinel Events,” Comprehensive Accreditation Manual for Behavioral Healthcare, 2016, https://perma.cc/9P7K-WXCB.

e. The Joint Commission, “Sentinel Events,” 3.

f. Health services departments at all eligible Bureau of Prisons institutions are accredited by The Joint Commission, for example. (Care Level 1 facilities are not eligible, because they serve healthy inmates.) Correctional facilities may opt for health care accreditation by the American Correctional Association or the National Commission on Correctional Health Care. All of these accreditation processes are voluntary.

"Defining suicide and self-harm" text box

a. Centers for Disease Control and Prevention, Definitions: Self-directed violence, August 15, 2016, https://perma.cc/SR5R-6VR3

b. Keren Skegg, “Self-harm,” The Lancet 366 (2005): 1471-1483.

c. Dixon-Gordon,  Harrison, and Roesch, 2012, 33-50; Jacqueline Mangnall and Eleanor Yurkovich, “A Literature Review of Deliberate Self-Harm,” Perspectives in Psychiatric Care 44, no.3 (2008): 175-184.

d. World Health Organization, Preventing Suicide: A Resource for Non-Fatal Suicidal Behavior Case Registration (Geneva, Switzerland: World Health Organization, 2014). 

e. Mumola, 2005; and Keith Hawton, Louise Linsel, Tunde Adeniji, Amir Sariaslan, and Seena Fazel, “Self-Harm in Prisons in England and Wales: An Epidemiological Study of Prevalence, Risk Factors, Clustering, and Subsequent Suicide,” The Lancet 383, no. 9923 (2014): 1147-1154.

f. Barent W. Walsh, Treating Self-Injury: A Practical Guide, 2nd Edition (New York: Guilford Press, 2012).