title: Quality of Quality Accounts: transparency of public reporting of Never Events in England. A semi-quantitative and qualitative review.
abstract: OBJECTIVE
  To describe the quality of reporting and investigation into surgical Never Events in public reports.
  
  
  METHODS
  Semi-quantitative and qualitative review of published Quality Accounts for three years (2011/2-2013/14). Data on Never Events were compared with previously collated Never Events rates. Quality of reported investigations was assessed using the London Protocol.
  
  
  METHODS
  English National Health Service.
  
  
  METHODS
  All English acute hospital trusts.
  
  
  METHODS
  Quality of Never Event reporting.
  
  
  RESULTS
  Quality Accounts were available for all Trusts for all three years, of which 342 referred to years when a surgical Never Event had occurred. A total of 125 of 342 (37%) accounts failed to report any or all Never Events that had occurred; 13/342 (4%) provided full disclosure; 197 (58%) reported that some investigation had taken place. Of these 197, 61 (31%) were limited in scope; 61 (31%) were categorised as detailed reports. Task and Technology factors were the commonest factor (103/211 (49%)) Identified in investigations, followed by Individual factors (48/211 (23%)). Team and Work environment factors were identified in 29/211 (14%) and 23/211 (11%), respectively. Organisational and Management 5/211 (2%) factors were rarely identified, and the Institutional context was never discussed.
  
  
  CONCLUSIONS
  Reporting of Never Events and their investigations by English NHS Trusts in their Quality Accounts is neither consistently transparent nor adequate. As with clinical error, the true root causes are likely to be organisational rather than individual.
authors.affiliation: University of Nottingham, Nottingham NG7 2RD, UK.
authors.forename: Nazurah Nn Abdul
authors.initials: NN
authors.lastname: Wahid
authors.affiliation: Queen's Medical Centre, Nottingham University Hospitals, Nottingham NG7 2UH, UK.
authors.forename: Sarah H
authors.initials: SH
authors.lastname: Moppett
authors.affiliation: Anaesthesia & Critical Care Section, Division of Clinical Neuroscience, Queen's Medical Centre, Nottingham University Hospitals, University of Nottingham, NG7 2UH, UK Iain.moppett@nottingham.ac.uk.
authors.forename: Iain K
authors.initials: IK
authors.lastname: Moppett
mesh_terms: D004739:England; D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data; D036301:Qualitative Research; D012308:Risk Management / Q000706:statistics & numerical data*
keywords: Never Events; Patient safety; Quality Accounts; candour; error; surgery; transparency