Sentinel events in prison: surveillance of dual-harming incarcerated populations

Abstract

Sentinel event review systems were created to prevent catastrophes from occurring in complex human organizations, though they have yet to be fully realized in corrections. Sentinel event reviews may be particularly salient for incarcerated people who engage in dual harming behaviors (i.e., self-harm and violence) given their overrepresentation in disciplinary incidents. To explore this potential, incident reports spanning a three-year period for an entire state prison system were examined. Our specific objectives were to assess the prevalence of institutional incidents committed by people who dual harm, and to identify their unique characteristics. Quantitative estimations indicated how dual harmers, in comparison to other incarcerated population members, were responsible for a higher proportion of disciplinary incidents. Further analyses indicated how people who dual harm were disproportionately more at-risk for mental health issues, and more likely to be housed in maximum-security facilities. Policy implications are discussed.