{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T09:02:58Z","timestamp":1789635778308,"version":"4.0.0"},"reference-count":31,"publisher":"BMJ","license":[{"start":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T00:00:00Z","timestamp":1789603200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Qual Saf"],"accepted":{"date-parts":[[2026,8,12]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Diagnostic safety concerns are among the most consequential yet least visible threats to patient safety in primary care. Non-specific symptoms potentially associated with cancer represent a high-risk context, where delayed diagnosis may have serious consequences despite a low probability of serious disease.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To identify diagnostic safety concerns and areas for improvement in assessing patients presenting with non-specific symptoms in primary care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method<\/jats:title>\n                    <jats:p>A structured medical record review combining quantitative assessment and qualitative thematic analysis was conducted in Region Stockholm, Sweden. In a region-wide quality improvement initiative, 27 primary care centres reviewed 1116 medical records of patients aged 40\u201375 years with selected ICD-10 (International Classification of Diseases, 10th Revision) codes recorded in 2023. Reviews used a structured template addressing diagnostic reasoning, data collection and healthcare use. Quantitative data were analysed descriptively, and qualitative data were analysed using reflexive thematic analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Overall, 358 records (32%) had at least one diagnostic safety concern. Absence of documentation of differential diagnostic reasoning was identified in 21% of records, insufficient data collection in 18% and failure to consider alternative diagnoses in 12%; these concerns co-occurred in 13% of records. Four themes were identified: invisible diagnostic reasoning, narrow diagnostic framing, failure to re-evaluate, and fragmented care and patient complexity as a cross-cutting contextual influence on diagnostic vulnerabilities.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Among patients presenting with non-specific symptoms potentially associated with cancer, documentation-related diagnostic safety concerns arose from whether and how diagnostic reasoning was documented, revisited and communicated across encounters. While the findings support safety-netting and diagnostic re-evaluation, they also highlight vulnerabilities including negative test results functioning as diagnostic endpoints and care fragmentation undermining diagnostic progression. Structured record review linked to reflective learning may help address these patterns in practice.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjqs-2026-020701","type":"journal-article","created":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T08:20:18Z","timestamp":1789633218000},"page":"bmjqs-2026-020701","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Documentation-related diagnostic safety concerns in primary care: a structured medical record review of 1116 patient records"],"prefix":"10.1136","author":[{"given":"Rita","family":"Fernholm","sequence":"first","affiliation":[{"name":"Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden"},{"name":"Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caroline","family":"Kappelin","sequence":"additional","affiliation":[{"name":"Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden"},{"name":"Liljeholmen Primary Care Centre, Region Stockholm, Stockholm, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9589-4681","authenticated-orcid":false,"given":"Elinor","family":"Nemlander","sequence":"additional","affiliation":[{"name":"Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden"},{"name":"Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,9,17]]},"reference":[{"key":"2026091701201083000_bmjqs-2026-020701v1.1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2020-012594"},{"key":"2026091701201083000_bmjqs-2026-020701v1.2","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2016-005401"},{"key":"2026091701201083000_bmjqs-2026-020701v1.3","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(15)00205-3"},{"key":"2026091701201083000_bmjqs-2026-020701v1.4","doi-asserted-by":"publisher","DOI":"10.1080\/13814788.2019.1625886"},{"key":"2026091701201083000_bmjqs-2026-020701v1.5","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2014-003675"},{"key":"2026091701201083000_bmjqs-2026-020701v1.6","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp10X515412"},{"key":"2026091701201083000_bmjqs-2026-020701v1.7","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp10X483175"},{"key":"2026091701201083000_bmjqs-2026-020701v1.8","doi-asserted-by":"crossref","first-page":"192","DOI":"10.1080\/13814788.2018.1491963","article-title":"Potential value of patient record review to assess and improve patient safety in general practice: A systematic review","volume":"24","author":"Madden","year":"2018","journal-title":"Eur J Gen Pract"},{"key":"2026091701201083000_bmjqs-2026-020701v1.9","doi-asserted-by":"crossref","first-page":"107148","DOI":"10.1016\/j.jebo.2025.107148","article-title":"Mixed payment and mixed objectives: insights from the ownership structure in Swedish primary care","volume":"237","author":"Hellbom Almstr\u00f6m","year":"2025","journal-title":"J Econ Behav Organ"},{"key":"2026091701201083000_bmjqs-2026-020701v1.10","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1080\/02813432.2025.2490921","article-title":"Enhancing primary care quality improvement through national data collection and validation: the primary care quality initiative in Sweden","volume":"43","author":"M\u00e5nsson","year":"2025","journal-title":"Scand J Prim Health Care"},{"key":"2026091701201083000_bmjqs-2026-020701v1.11","first-page":"723","article-title":"Patients\u2019 Online Access to Electronic Health Records: Current Status and Experiences from the Implementation in Sweden","volume":"245","author":"H\u00e4gglund","year":"2017","journal-title":"Stud Health Technol Inform"},{"key":"2026091701201083000_bmjqs-2026-020701v1.12","unstructured":"Regionala cancercentrum i samverkan . Standardiserat v\u00e5rdf\u00f6rlopp allvarliga ospecifika symtom [Standardized patient pathway for serious non-specific symptoms]. 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A systematic review of continuity of care and mortality","volume":"8","author":"Pereira Gray","year":"2018","journal-title":"BMJ Open"},{"key":"2026091701201083000_bmjqs-2026-020701v1.26","doi-asserted-by":"crossref","first-page":"100016","DOI":"10.1016\/j.lanprc.2025.100016","article-title":"Continuity of care in general practice and patient outcomes in Denmark: a population-based cohort study","volume":"1","author":"Prior","year":"2025","journal-title":"Lancet Primary Care"},{"key":"2026091701201083000_bmjqs-2026-020701v1.27","first-page":"1","article-title":"Sweden: Health System Review","volume":"25","author":"Janl\u00f6v","year":"2023","journal-title":"Health Syst Transit"},{"key":"2026091701201083000_bmjqs-2026-020701v1.28","doi-asserted-by":"crossref","DOI":"10.1136\/bmjonc-2025-001038","article-title":"Incident anaemia as a marker of cancer and all-cause mortality: evidence from 380 114 adults in the population-based Stockholm Early Detection of Cancer Study (STEADY-CAN) cohort","volume":"5","author":"Nemlander","year":"2026","journal-title":"BMJ Oncol"},{"key":"2026091701201083000_bmjqs-2026-020701v1.29","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.r2000","article-title":"Jess\u2019s rule: GPs urged to use \u201cthree strikes and rethink\u201d approach to prevent patient deaths","volume":"390","author":"Wise","year":"2025","journal-title":"BMJ"},{"key":"2026091701201083000_bmjqs-2026-020701v1.30","doi-asserted-by":"crossref","unstructured":"Fornara O , Ekblad S , Fernholm R , et al . Learning from patient safety incidents in primary care: a Swedish mixed-methods study. 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