Learning from patient safety incidents in primary care: a Swedish mixed-methods study

Area of Science:

• Healthcare Management
• Patient Safety Research
• Primary Care Medicine

Background:

• Primary care clinicians face time pressures and diagnostic uncertainty with evolving symptoms.
• Patient safety incidents arise from complex clinical, organizational, and communication factors.
• Limited understanding exists on local interpretation of incidents and their translation into organizational improvements.

Purpose of the Study:

• Examine patient safety incidents in Swedish primary care.
• Identify factors contributing to these incidents.
• Explore how incident analysis supports organizational learning and patient safety enhancement.

Main Methods:

• Mixed-methods study in Region Stockholm, Sweden.
• Utilized incident reports from tax-funded primary care centers.
• Employed descriptive statistics and reflexive thematic analysis of structured and free-text data.

Main Results:

• Included 696 incident reports from 34 centers; 71% deemed avoidable, 37% involved diagnostic delay.
• Identified five key contributory factor groups: staff, patient, work environment, administrative processes, and care coordination.
• Learning actions included education, supervision, improved routines, staffing, safety-netting, patient involvement, and communication.

Conclusions:

• Incident reports reveal persistent vulnerabilities in primary care follow-up, communication, and organizational processes.
• Regular local incident review facilitates organizational learning.
• This process can inform practical strategies for enhancing patient safety in primary care.