ABSTRACT

Trust between law enforcement officers and the communities they serve is essential to the safety of our citizens. Relationships between police and communities have, however, become increasingly strained, with reports of deadly events and wrongful convictions filling the television, newspapers, and the Internet. While the model of conducting internal investigations to determine blame and penalize the individuals involved has been used for years, a new paradigm to bring systemic change is increasingly being embraced by the criminal justice field. Historically used in other disciplines, sentinel event reviews have been employed to understand organizational failures. Multiple key community stakeholders gather to conduct a root cause analysis, which is an empirical approach that involves data collection to understand the systems-level causes of organizational events. The purpose of this paper is to examine the literature on sentinel event reviews in the criminal justice system, borrowing heavily from other disciplines where they are already well-established. We then examine the literature on organizational adoption, since the ultimate goal of sentinel event reviews is to lead to stronger systems that can learn from systemic mistakes and allow the dissemination of best practices to benefit both law enforcement and the individuals they serve.

摘要

执法人员与他们服务的社区之间的信任对于我们公民的安全至关重要。但是，警察，社区之间的关系变得越来越紧张，有关致命事件和错误定罪的报道充斥着电视，报纸和互联网。虽然进行内部调查以确定责任人和惩罚相关个人的模型已经使用了多年，但刑事司法领域越来越多地采用一种新的范式来进行系统的改变。历史上在其他学科中使用过，前哨事件审查已用于了解组织失败。多个关键的社区利益相关者聚集在一起进行根本原因分析，这是一种经验方法，涉及数据收集以了解组织事件的系统级原因。本文的目的是研究刑事司法系统中有关前哨事件审查的文献，并大量借鉴已经建立的其他学科。然后，我们审查有关组织采用的文献，因为前哨事件审查的最终目标是建立更强大的系统，可以从系统性错误中吸取教训，并传播最佳做法，从而使执法部门和所服务的个人受益。