Learning From Errors to Improve Justice Outcomes

Every error that occurs in our criminal justice system inflicts specific harm—an individual is wrongfully convicted, a criminal goes free, a victim is deprived of justice, a community is ill-served—and the agencies of justice emerge more tarnished and less trusted than before. Addressing the specific harm alone is not enough. Errors must be recognized as potential “sentinel events” that can signal more complex flaws that might threaten the integrity of the system as a whole.

Drawing on lessons from medicine and aviation, our latest report, Mending Justice: Sentinel Event Reviews, explores the feasibility of using a learning-from-error model in criminal justice. In the primary essay, James Doyle, a former NIJ Visiting Fellow, writes that a sentinel event is rarely the fault of a single individual. Rather, multiple small errors combine and are exacerbated by underlying system weaknesses, and then a major error occurs. Based on this “organizational accident” principle, a sentinel event review would bring all stakeholders together to examine the error in a nonblaming and forward-looking way.

With a message from Attorney General Eric Holder and 17 commentaries from nationally recognized criminal justice professionals, Mending Justice offers perspectives on an innovative approach that uses nonblaming reviews involving all stakeholders in the improvement of the criminal justice system and its outcomes.

Read Mending Justice: Sentinel Event Reviews.

Source: NIJ

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Digital-Image Management at Mass Gravesites

SKELETONIZED REMAINS that were carefully unearthed from the desert sands of Iraq tell their own story: the bones of an adult, still dressed in a woman’s apparel, lie supine. The skull is perforated by a bullet hole. Tucked in the space between the ribs and the left humerus is a much smaller skeleton, bones in the skull un-fused, and the fully clothed body partially swaddled in a blanket.