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NCJ Number: 250521 Find in a Library
Title: Creating a Culture of Safety: Sentinel Event Reviews for Suicide and Self-Harm in Correctional Facilities
Author(s): Leah Pope; Ayesha Delany-Brumsey
Corporate Author: Vera Institute of Justice
United States of America
Date Published: December 2016
Page Count: 33
Sponsoring Agency: National Institute of Justice (NIJ)
Washington, DC 20531
Vera Institute of Justice
New York, NY 10279
Grant Number: 2014-IJ-CX-0030
Sale Source: Vera Institute of Justice
233 Broadway, 12th Floor
New York, NY 10279
United States of America
Document: PDF
Type: Instructional Material; Report (Grant Sponsored); Report (Technical Assistance)
Format: Document; Document (Online)
Language: English
Country: United States of America
Annotation: This report provides guidance on what correctional agencies can learn from other fields in countering suicide and self-harm among residents of correctional facilities, notably the health community’s and the aviation community’s practice of viewing adverse outcomes in their fields as “sentinel events” that require a reassessment of their systems and practices so as to prevent similar adverse outcomes in the future.
Abstract: This report embraces the protocol of conducting an all-stakeholder, non-blaming, forward-looking, and reformative review process of every incident of suicide or attempted suicide or of self-harm involving a correctional facility resident. This “sentinel event” approach resists blaming individuals for the event, as it encourages an ethic of shared responsibility in which all parties examine the various factors that contributed to the occurrence of the sentinel event. This is followed by the development and implementation of changes in facility policies and practices that will counter the factors believed to have led to the sentinel event. Steps outlined for such a protocol are to identify the sentinel event; convene a multidisciplinary team; describe the event/create a timeline; identify contributing factors; identify the root causes; develop an action plan; share lessons learned; and measure the success of corrective actions. Some potential challenges for implementation of this review process in correctional facilities are categorized as logistical, interactional, and structural challenges; confidentiality concerns; and concerns about legal liability. 65 notes and a list of resources
Main Term(s): Corrections policies
Index Term(s): Change management; Corrections management; Inmate suicide; Multidisciplinary Teams; NIJ grant-related documents; Self-Injurious Behavior
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