Search results
An SER should be conducted whenever a sentinel event occurs. A sentinel event is a significant negative outcome or a “near miss” that signals underlying weaknesses in the system and/or is likely the result of multiple compounding errors. In aviation, a sentinel event might be a plane crash or a situation where a crash is averted due to luck ...
NCJ 249097. PAVING THE WAY: LESSONS LEARNED IN SENTINEL EVENT REVIEWS. When bad things happen in a complex system, the cause is rarely a single act, event or slip-up. More often, bad outcomes are “sentinel events.”. A sentinel event is a negative outcome that: • Signals underlying weaknesses in a system or process.
- 545KB
- 24
Jul 31, 2019 · University of Pennsylvania Law School. Correspondence. John F. Hollway, University of Pennsylvania Law School, 3501 Sansom Street, Philadelphia, PA 19104. Email: [email protected] Search for more papers by this author
- John F. Hollway, Ben Grunwald
- 2019
College of William & Mary Law School ... should develop its own definition of a sentinel event, as well as procedures and methods for investigating the causes
The Quattrone Center has developed a proven approach to conducting Sentinel Event Reviews (SER) in criminal justice, learning from errors including officer-involved shootings (OIS), deaths in custody (DIC), and wrongful convictions (WC) among other undesired outcomes. SER is a voluntary, confidential process that applies principles of root ...
Jan 1, 2014 · Abstract. A sentinel event is a significant negative outcome that: 1) signals underlying weaknesses in the system or process; 2) is likely the result of compound errors; and 3) may provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse events or outcomes.
Keywords: criminal justice policy, systems approach, law enforcement, policing, procedural justice, quality improvement, root cause analysis, sentinel event review, organizational management Suggested Citation: Suggested Citation
