Background:

Early identification of potential cancer symptoms in primary care is challenging, yet most patients with cancer first present in this setting. Prioritising patients with suspected cancer places demands on primary care clinicians and missed or delayed cancer diagnoses account for a proportion of diagnostic errors. Understanding system and process failures is essential for learning and improvement.

Research questions:

To examine system and process failures contributing to diagnostic delay in primary care through a structured review of patient safety incident reports in Sweden.

Method:

We conducted a mixed-methods study in primary care in Region Stockholm, Sweden. Patient safety incident reports related to diagnostic delay were identified from a region-wide incident reporting system. All primary care centres were invited to contribute anonymised reports. Descriptive statistics summarised incident characteristics. Free-text responses to two predefined template questions were analysed separately using reflexive thematic analysis.

Results:

Thirty-four primary care centres contributed 696 incident reports; 71% involved patient harm or potential harm considered avoidable. Diagnostic delay was identified in 38% of reports, approximately one third of which were cancer-related.
Reported contributory factors were mainly clinician- and practice-level: gaps in clinical knowledge, unclear or poorly adhered-to routines, and human factors leading to missed follow-up or delayed re-assessment. Additional factors included patient-related disruptions, work pressures, administrative or IT failures, and poor coordination across care transitions.
Suggested learning and improvement actions focused on standardising diagnostic and follow-up routines, targeted education, strengthening patient-centred communication and safety-netting, improving working conditions and continuity of care, and enhancing collaboration and information sharing across organisational boundaries.

Conclusions:

Synthesising patient safety incident reports from multiple primary care centres provides system-level insight into diagnostic pathway failures. Delays were linked to recurring, modifiable process weaknesses rather than isolated mistakes. Systematic use of incident data can inform practical, transferable interventions to support earlier cancer detection and reduce avoidable diagnostic delays in primary care.

Points for discussion: