Using sentinel event reviews to address suicide and self-harm

The prevalence of incidents of suicide and self-harm in correctional facilities—and the fact that current responses are often fragmented and fail to account for the multiple systems and actors (such as health providers and correctional officers) involved in the operations of a correctional facility—suggest that these events are particularly ripe for a sentinel event review process.

            Although there are various methods for carrying out sentinel event reviews, the RCA methodology is used most commonly and has the most available evidence for its effectiveness.26 For example, individual criminal justice systems—such as New York City and State and Montgomery County, Pennsylvania, which were mentioned in previous examples—have successfully incorporated the use of RCA methodology into their practices.27 In addition, The Joint Commission encourages the use of RCAs and the Veterans Health Administration requires that an RCA is conducted for certain adverse events.

            In health care settings, a small but growing body of work has shown that the use of RCA can improve safety and is associated with decreased mortality during hip surgery, increased survival rates for liver transplants, and fewer adverse drug events.28 There is also research demonstrating that RCAs can improve collaboration and enhance shared decision-making in response to errors. For instance, one survey of health professionals who conducted RCAs found that more than 80 percent of respondents believed RCAs improved work practices, facilitated teamwork, and improved communication about patients. Another study found that over 75 percent of respondents who had attended RCA training felt that it enabled them to improve work processes for the provision of a safer clinical culture.29 Indeed, when an event occurs that results in an undesirable outcome, RCA has been widely adopted as a powerful method to examine an organization’s processes and systems and determine what happened, why it happened, and what can be done to prevent it from happening again.30

            Certainly, more evaluative work of RCAs—and of sentinel event reviews more broadly—is warranted. This is particularly true in the criminal justice system, where the feasibility of conducting sentinel event reviews is just beginning to be established and where research is needed that examines how sentinel event reviews can improve system functioning and avoid future errors.31 Even so, the fact that RCAs have been used successfully in a growing number of criminal justice systems and has long been recommended as standard practice in health care and other fields suggests the criminal justice field may find great utility in this methodology.