Imagining Sentinel Event Reviews in the U.S. Probation and Pretrial Services System

In normal operations, practical drift from policy and procedures may go unnoticed, but in a high-profile situation any deviation from policy will be scrutinized. Conducting system-wide reviews can help uncover practical drift at all levels of an organization. The authors ask whether the federal criminal justice system can develop this capacity for "forward-looking accountability," accepting error as an inevitable element of the human condition, studying known errors in a disciplined and consistent way, sharing the lessons learned to prevent future errors, and focusing on future risks rather than on blame for the past.