Justice Systems Test “Sentinel Event Analysis” To Prevent Mistakes

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“Sentinel event analysis,” a process traditionally not used in criminal justice but entrenched in the health-care and transportation industries, now is being tested to help prevent major justice errors, the New Yorker magazine reports. Boston defense attorney James Doyle observed the proliferation of exoneration cases in the post-DNA era and worked on reform efforts. “No one gets into this job to convict innocent people,” he says. “The real problem is developing the capability for dealing with inevitable mistakes.” He wondered if sentinel event analysis, or reviewing legal errors in a blame-free environment, could tease out the sequence of factors that contributed to a mistake and lead to a more accident-proof legal system.

Sponsored by the National Institute of Justice, Doyle travelled the U.S. interviewing police, prosecutors, defense attorneys, and victims’-rights groups, and others, culminating in meeting in Washington, D.C. Based on his work, the institute organized an experiment in which Milwaukee, Baltimore, and Philadelphia—volunteered to do a systems analysis of a high-profile failure. A Montgomery County experiment described by the magazine, conducted in parallel with the NIJ study, was a fourth.

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