This report summarizes the key achievements of the National Institute of Justice's (NIJ's) June 2017 All-Stakeholder Forum in support of the Sentinel Events Initiative (SEI), which is an effort to guide criminal justice agencies in how to achieve improvements in the justice system through a structured analysis of adverse events in the justice system's functioning (sentinel events).
The participants consisted of nearly 100 federal, state, and local criminal justice practitioners, researchers, academics, policymakers, community representatives, and federal partners. They discussed mechanisms for "learning-from-error" in managing the criminal justice system. The Forum explored the potential benefits of developing the capacity for state and local sentinel-event reviews (SERs); discussed how lessons learned from instilling sustainable cultures of safety in the medical and aviation fields might be applied in criminal justice; explored existing research in criminal justice and related fields; identified aspects of technical assistance necessary to support local system-wide reviews; and created a shared understanding of common goals and anticipated products from SERs, while allowing for appropriate local variations. The Forum's proceedings are summarized under the following topics: 1) guiding theories and principals; 2) additional benefits of sentinel event reviews; 3) considerations and activities for technical assistance and neutral conveners; 4) considerations for case selection; 5) considerations for the review process and outcome; and 6) open questions.