[Music] I'd like you to meet Marshall Hail. In 1984, Mr. . Hail, then 24 years old, was arrested, charged, and convicted for the rape of a teenage girl in Philadelphia.33 years later, in 2017, the Philadelphia District Attorney's Office re reviewed removed all charges for Mr. . Mr. . Hail and moved for his immediate release on the basis of a blood test that showed conclusively that Mr.. Hail was not in fact the rapist. The blood test that secured Mr. . Hail's release was actually conducted by the Philadelph ...

Criminal Justice System Errors - The National Registry of Exonerations has cataloged over 3,600 instances of wrongful convictions, resulting in over 33,000 life years served [6] - Analysis of death penalty cases suggests a 4% error rate, potentially meaning 90 out of 2,250 death row inmates are innocent [17][18] - Even with a conservative estimate of a 2% error rate in criminal justice, there would be 7,500 mistakes in every 300,000 trials [19] Comparison with Other Industries - In transportation, approximately 3 injuries occur per 300,000 car trips, equating to a 0001% injury rate [12] - In medicine, there are about 25 "never events" per 300,000 surgeries [15] - Criminal justice error rates are significantly higher than those in transportation and medicine [20] Sentinel Event Reviews - Transportation and medicine industries use "sentinel event reviews" (blame-free root cause analysis) to understand and prevent errors [21] - Sentinel event reviews involve presuming talent and training, focusing on systemic issues rather than individual blame [23] - Applying sentinel event reviews to Marshall Hail's case revealed 46 contributing factors and led to 29 recommendations for change [40] Swiss Cheese Model - The "Swiss cheese model" illustrates how errors occur when multiple layers of checks and balances (slices of cheese) all have holes that align [31][32][33][34] - Sentinel event reviews aim to close the holes in each slice of Swiss cheese to prevent errors from slipping through [35] Potential Impact of Sentinel Event Reviews - Aviation industry's use of sentinel event reviews has dramatically reduced fatal plane crashes over 50 years [46] - Implementing sentinel event reviews in criminal justice could prevent wrongful convictions, officer-involved shootings, and deaths in custody [53]