A woman who seeks care for blood in the stool is told that a referral for a colonoscopy must be written.

More than six months later, she learns that the health center failed to send the referral.

Once the examination is done, it turns out that she has cancer. 

Another patient seeks care at a health center due to pressure over the chest and cold sweats.

The patient's ECG is assessed incorrectly and he is sent home.

Within 24 hours, the patient is back, then with an acute heart attack. 

These are two examples of reports that care providers have sent to the Swedish Health and Care Inspectorate, Ivo, in recent years.

The cases concerning primary care are many and the most common is that a patient, relative or care provider is behind the report.

Late diagnoses cause the most serious injuries

Most people report mistakes or shortcomings that they believe have led to a diagnosis or treatment being delayed.

Of just over 1,000 cases that SVT Nyheter went through from three typical months during the years 2018, 2019 and 2021, 35 percent are about it.

In most of these cases, it is the care provider himself who has reported and thus established that an error has been committed.

- Late diagnoses cause the most serious injuries in primary care, says Rita Fernholm who is a general practitioner and researches patient safety issues at Karolinska Institutet.

When, for example, a cancer diagnosis is delayed, the cancer can spread, and that is very serious.

Low staffing of general practitioners, inadequate routines and unclear communication between doctors and patients are factors that Rita Fernholm believes often contribute to healthcare injuries.

Inadequate routines and staff shortages are something that is also mentioned in several of the Ivo reports.

In the case of the patient whose ECG was assessed incorrectly, for example, the care provider writes: "The underlying causes of the incident were high patient pressure and reduced staffing".

"Swedish primary care does not work"

Several doctors that SVT Nyheter has been in contact with also talk about staff shortages and how it endangers patient safety on a daily basis.

- Swedish primary care does not work as you want it today.

Staffing and competence are the cornerstones of primary care.

If this is not the case, it is difficult to provide patient-safe care, says Rita Fernholm.

* Reports mean reports of errors in care, questions, complaints and lex Marior that have been received by Ivo.