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Conducting a Sentinel Event Review (SER)

The SER Process

The SER process is designed to promote organizational learning and quality & safety improvement in a non-blaming, “just culture” atmosphere that recognizes that talented, well-trained criminal justice professionals can nonetheless become involved in unacceptable events.

Innovations in Criminal Justice: The 2023 Quattrone Center Spring Symposium

When to conduct a SER

Sentinel Event Reviews are a form of “forward-looking” accountability as organizations and communities reacting to an undesired outcome (e.g., wrongful convictions, violence by or against police, deaths in custody, etc.) evaluate the bad event and design recommendations carefully tailored to prevent its recurrence.

In doing this, SERs increase quality and safety, increase public trust and organizational pride and improve relationships between the community and law enforcement. Participants in Quattrone Center SERs – including both members of criminal justice agencies and community members – often comment that the process increased their understanding of each other, in addition to improving their ability to work collaboratively to find solutions.


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 rather than planning. In healthcare, a sentinel event might be a surgery on the wrong limb, or leaving a surgical implement inside a body cavity, or a patient acquiring an infection in a hospital that the patient did not have upon admission.

The Quattrone Center’s interdisciplinary team has successfully facilitated SERs in criminal justice examining a wide range of “errors” including officer-involved shootings (OIS), death in custody (DIC), wrongful convictions, improper incarcerations, uses of force by and against police during protests and civil unrest, forensic errors, domestic violence fatalities, opioid-induced fatalities, and others. Our reviews have been conducted in jurisdictions across the country, including cities and counties in Arizona, California, Maryland, Minnesota, Pennsylvania, Texas, Washington, Wisconsin and elsewhere.

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Conducting the SER

Every sentinel event is by definition an event that we have already labeled as undesired or unintended.  So by definition, each sentinel event occurs despite our best efforts to prevent it. Because these events have eluded our existing policies and procedures designed to prevent it, and because each jurisdiction’s policies and procedures are unique, each SER is unique. The Quattrone Center’s SER process is adaptable to the facts and circumstances of each event, jurisdiction, and community. What remains the same across every SER are its key guiding principles: collaborative partnerships; a high-accountability culture focused on system improvement, not individual blame; the ability to create spaces for difficult conversations and the sharing of diverse perspectives; and transparency.

Behind every sentinel event is a cascade of interactions, administrative processes, communications, information silos, tactical considerations, equipment issues, and socioeconomic and cultural factors. The SER process carefully examines these interactions from the perspective of what each participant knew at the time and what drove their decision-making, and identifies contributing factors for a specific error. From there, the reviewers develop an action plan to address those factors and prevent future errors.

Learn more and explore case studies


Who participates?

Our SERs typically consist of representatives from each agency that participated in the sentinel event, as well as community representatives, subject matter experts, and other important stakeholders.  The Quattrone Center functions as a moderator and facilitator helping the reviewers reach consensus on the factors that contributed to the sentinel event and on implementable recommendations for change.


What does the process look like?

Each SER is unique, and the exact process and duration depends on the scale and scope of the event under review. For example, a review of a 10-minute interaction with law enforcement will look different from a review of an exoneration involving a case that spanned several years.

Once a call for review has been initiated, the Quattrone Center collaborates with the jurisdiction to convene the SER team to begin the review.



Working with the Quattrone Center

Innovations in Criminal Justice: The 2023 Quattrone Center Spring Symposium

A National Leader in a Systems Approach to Justice Reform

The Quattrone Center is the only institute offering this kind of expert analysis to jurisdictions across the country.

Our work is data-driven, backed by decades of research, and led by the nation’s leading experts in criminal justice and systems reform work.

Investing in Sustainable Change

The Quattrone Center is committed to creating lasting structural improvements to the criminal justice system. Contact our team to learn more about ways to offset costs of conducting a review.

Contact our team to learn more

How can the Quattrone Center help?

We are committed to helping jurisdictions eliminate errors and improve the quality of the justice system.

Contact us