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

Abstract

Primary care clinicians often work under time pressure and diagnostic uncertainty while managing undifferentiated and evolving symptoms. Patient safety incidents in this setting may arise through interacting clinical, organisational, and communication-related factors. However, little is known about how reported incidents are interpreted locally and translated into organisational improvement. To examine reported patient safety incidents in Swedish primary care, identify contributory factors, and explore how incident analysis can support organisational learning and patient safety improvement. Mixed-methods study in Region Stockholm, Sweden, using incident reports from primary care centres within a tax-funded universal healthcare system. Descriptive statistics summarised key variables from structured incident review forms. Free-text data on contributory factors and organisational learning were analysed using reflexive thematic analysis following Braun and Clarke's six-phase approach. A total of 696 incident reports from 34 centres were included. Most incidents were judged avoidable (71%), and 37% involved diagnostic delay. Five groups of contributory factors were identified: staff-related factors, patient-related factors, work environment, administrative processes, and coordination across care boundaries. Reported learning and improvement actions largely mirrored these factors and included continuing education and supervision, clearer follow-up routines, improved continuity and staffing, enhanced safety-netting and patient involvement, and more timely communication between providers. Incident reports highlight recurring vulnerabilities in follow-up, communication, and organisational processes in primary care. Regular local review can support organisational learning and inform practical measures to improve patient safety in primary care.