Since 2011, the National Institute of Justice (NIJ), through its Sentinel Events Initiative, has been investigating the feasibility of using a sentinel events approach to review and learn from errors in the criminal justice system such as wrongful convictions, eyewitness misidentifications, or incidents of suicide and self-harm in custody.1 Recognizing that adverse situations are rarely caused by a single event or the actions of an individual person, NIJ defines a sentinel event as a significant negative outcome that: 1) signals underlying weaknesses in a system or process; 2) is likely the result of compound errors; and 3) may provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse events or outcomes.2  

            The fields of aviation and medicine have long used sentinel event reviews as a way to account for significant, unexpected negative outcomes, and to leverage the knowledge gleaned from the review process to reduce future errors (see section on “Sentinel event reviews in aviation and medicine.”)3 These reviews are intended to be non-blaming, systemwide, and forward-looking—to prevent future errors by creating an ethic of shared responsibility and a culture of safety.4 Taking the examples set in these fields, leaders in criminal justice also have come to recognize that system errors might be better conceived as sentinel events that speak to larger systemic problems.

            Indeed, there is a growing body of literature and there are increasing examples from the field to suggest the utility of a systems approach in reducing errors in the criminal justice system. Several jurisdictions have recently used the process of root cause analysis (RCA)—a methodology  that can be used to carry out sentinel event reviews—to examine why an adverse event occurred. For example, the New York State Justice Task Force formed a root cause analysis subcommittee in December 2014, which led to the recommendation that RCAs be used to respond to adverse events across the state’s criminal justice system. And in Montgomery County, Pennsylvania, the office of the district attorney’s use of RCA revealed that a lab report had been misread, which led to the dismissal of an indictment.5

            NIJ’s Sentinel Events Initiative has undertaken a broader and more robust effort to understand whether actors across various parts of the criminal justice system can adopt sentinel event reviews as a means for creating a “culture of safety” that leads to greater system reliability and enhanced public confidence in the system’s integrity.6 The initiative has included a research fellowship to gather feedback from criminal justice practitioners and researchers in the field; beta projects in Baltimore, Milwaukee, and Philadelphia that provided empirical evidence for the feasibility of such reviews in the justice system (sites designed and conducted their own review of a justice error that had occurred in their jurisdiction); and ongoing research projects on topics ranging from wrongful convictions to gun homicide and non-fatal shootings.

            With funding from NIJ, the Vera Institute of Justice (Vera) has been examining the applicability and appropriateness of using sentinel event reviews for incidents of suicide and serious self-harm in detention.7 Suicide is the leading cause of death in jails and 85 percent of U.S. prison systems report that self-injurious behavior occurs at least once a week.8 This report focuses on these incidents as prime opportunities to implement sentinel event reviews in the criminal justice context. It takes significant direction from the health care field since suicide and self-harm are health-related issues and health care facilities must frequently face and respond to such incidents (see section on “Sentinel event reviews in aviation and medicine”). The aim of this report is threefold: to provide an overview of the problem of suicide and self-harm in correctional facilities and describe the insufficiency of current responses; to outline the current evidence for the feasibility of sentinel event reviews in the criminal justice system and highlight potential implementation challenges; and to offer guidelines for conducting a sentinel event review in response to an incident of suicide or serious self-harm in a correctional facility. In so doing, this report contributes to the momentum for adopting a more institutionalized process of diagnosing and addressing errors in the criminal justice system.

Sentinel event reviews in aviation and medicine

In the mid-1970s, the Federal Aviation Administration created the Aviation Safety Reporting System for mandatory and confidential reporting of errors and “near-misses.” The National Transportation Safety Board compiles and publishes reports on all significant events.a

The medical field also has a long tradition of conducting multidisciplinary reviews of medical errors and adverse outcomes. The Morbidity and Mortality Conference—a regularly occurring meeting that provides clinicians with the opportunity to review adverse events—has been a standard forum for medical resident and continuing education since the early 20th century.b Beginning in the 1990s, however, academics and practitioners increased their attention to the problem of medical error and to making good on the system’s promise to “first, do no harm.” Reports by both the Institute of Medicine and Lucian Leape, a leader in the field of medical error, encouraged the field to move away from a view of error as solely the product of individual negligence and to adopt instead an institutionalized approach that identifies root causes and underlying system failures.c

The Joint Commission—a major independent accreditation body for U.S. health care organizations and programs—has had a Sentinel Event Policy in place since 1996 to review patient safety events that are not primarily related to the natural progression of the patient’s illness or underlying condition, and that result in death, permanent harm, or severe temporary harm.d The Joint Commission’s policy requires a “comprehensive systematic analysis for identifying the causal and contributory factors” as well as “strong corrective actions that provide effective and sustained system improvement.”e All sentinel events that occur in accredited health care facilities, which include some correctional facilities, must be reviewed by the organization and are subject to review by The Joint Commission.f Because health care facilities such as psychiatric units also face the issue of suicide and self-harm among their patient populations, applying sentinel events reviews from the medical field to a correctional setting is particularly promising.