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Learning from Error in the Criminal Justice System

Tuesday, September 16, 2014
By Karol Mason, Assistant Attorney General for the Office of Justice Programs

Karol Mason

I am pleased to announce the release of a new publication from OJP’s National Institute of Justice, Mending Justice: Sentinel Event Reviews, a report that breaks new ground on ways to strengthen the criminal justice system and avoid costly errors.

"The effectiveness and legitimacy of our justice system depend as much on the way it handles its mistakes as it does on how it carries out its core enforcement, prosecutorial, and correctional functions," says Attorney General Eric Holder in his introduction to the report. "Because ours is an institution set up to discover the truth, tolerance for mistakes is exceptionally low. But as justice system professionals, we are deceiving ourselves if we think our decisions and actions are infallible."

System errors are rarely the fault of a single actor, as other professions such as medicine and aviation have learned. Until recently, for example, when a hospital patient was the victim of a surgery intended for another patient or contracted a serious hospital-borne infection, the hospital would typically look for a nurse, doctor, or other employee to blame, and then quickly move on. This unthinking reflex response often drove disclosures of mistakes underground and doomed the hospital to see these kinds of bad outcomes repeated. Research showed that dozens of patient care decisions, made by competent and well-intended health professionals, often contributed to a serious system error. Today, many hospitals have adopted an all-stakeholder, non-blaming, forward-looking approach to learn from system errors in order to strengthen processes and make errors less likely to occur. The aviation industry has made a similar commitment to uncovering complex system errors by reviewing them in ways that diminish the need to blame someone and increase the likelihood of candid disclosure of actions and decisions that may have contributed to the error.

What about the criminal justice system? We certainly see our share of bad outcomes, such as wrongful conviction, ill-advised release from prison, repeated victimization, cold cases that remain unsolved too long, or high rates of failure on probation and parole. These events are "sentinels," in that they may signal underlying weaknesses in the criminal justice system and its processes. We know first-hand how finger-pointing and blame-placing can prevent an accurate understanding of what went wrong. What we need is a way to learn from these sentinel events so that the underlying frailties in the system are addressed, and the likelihood of similar bad outcomes in the future is lessened.

This year, the National Institute of Justice began a program of research to test whether the lessons and strategies of learning from error adopted in medicine, aviation, and other industries can take root in the justice system. Mending Justice: Sentinel Event Reviews is a first pivotal step in that program of research.??The report outlines ways the justice system could adopt sentinel event reviews to strengthen the systems and processes of justice, just as hospitals have used the approach to prevent the deaths of more than 100,000 patients. The report includes 17 commentaries from justice practitioners—police chiefs, prosecutors, defense counsel, and others, including research experts—that describe how such an approach might work in the criminal justice system.

Who should read Mending Justice? The answer is on the Department of Justice seal: "Qui pro domina justitia sequitur," loosely translated as anyone who works on behalf of justice. I would extend that mandate to anyone who seeks to ensure justice for all, and invite you to read it here:

This report is just one of many steps the National Institute of Justice has taken to explore applying a sentinel event approach to criminal justice. Other steps include the launch of three pioneering "beta" sites that are conducting their own sentinel event reviews and awarding several grants to research how sentinel event reviews could best work for criminal justice.

As the Attorney General reminds us, "If we truly hope to get to the bottom of errors and reduce the chances of repeating them, then it is time we explore a new, system-wide way of responding, not by pointing fingers, but by forthrightly assessing our processes, looking for weaknesses in our methods, and redesigning our approach so that the truth will be more attainable."

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