In the criminal justice system, things can go terribly wrong: convictions of the innocent, or killings of unarmed suspects.  We use the courts and investigations try to see who’s to blame.  But we do little to learn ways to stop it from happening again.  Using procedures from the worlds of medicine and aviation as a guide, attorney James Doyle has become the leading advocate for using Sentinel event analysis as way to understand and fix systemic problems in criminal justice.