Diagnostic Safety in Primary Care: What Bangladesh Can Learn from a New Study

Clinical documentation is more than record-keeping. It is a fundamental component of patient safety, diagnostic accuracy and continuity of care.

A diagnosis may appear reasonable at the time of consultation. But can another clinician understand the reasoning behind it? Were alternative diagnoses considered? Were investigations followed up? Was the patient advised what to do if symptoms persisted or worsened?

These questions are central to diagnostic safety—and increasingly important for healthcare quality improvement in Bangladesh.

A study published in BMJ Quality & Safety on 17 September 2026 offers useful insights into how gaps in clinical documentation may reveal weaknesses in the diagnostic process.

What Did the Study Find?

In Documentation-related diagnostic safety concerns in primary care: a structured medical record review of 1116 patient records, Rita Fernholm, Caroline Kappelin and Elinor Nemlander examined medical records from 27 primary care centres in Stockholm, Sweden.

The study focused on patients aged 40–75 years presenting with selected non-specific symptoms that could potentially be associated with cancer.

The findings highlighted several concerns:

• 32% of records contained at least one diagnostic safety concern.
• 21% lacked documented differential diagnostic reasoning.
• 18% showed insufficient data collection.
• 12% did not document consideration of alternative diagnoses.

These findings should be interpreted carefully. The study identified concerns in documentation and the diagnostic process; it did not establish that every concern represented a diagnostic error or resulted in patient harm.

Nevertheless, the findings demonstrate why structured medical record review can be a useful tool for identifying opportunities to improve diagnostic safety.

Reference: Fernholm R, Kappelin C, Nemlander E. BMJ Quality & Safety. 2026. Read the original study.

Why Does Clinical Documentation Matter for Patient Safety?

Clinical documentation provides a record of what was known, what was considered and what actions were planned during a patient’s care.

When documentation is incomplete, several problems may arise.

1. Clinical reasoning becomes difficult to follow

A record that contains only symptoms, test results and a final diagnosis may not explain why that diagnosis was selected or whether important alternatives were considered.

Clear documentation supports clinical review, continuity of care and learning from diagnostic uncertainty.

2. Persistent symptoms may be overlooked

A reassuring initial assessment does not always exclude serious disease. If symptoms persist, worsen or change, reassessment may be necessary.

Documented follow-up plans and clear safety-netting instructions help patients and clinicians recognise when further action is needed.

3. Fragmented information can disrupt continuity of care

Patients may move between primary care facilities, diagnostic centres, specialists and hospitals. If previous findings, pending investigations or referral decisions are not communicated effectively, important information may be missed.

4. Quality problems may remain invisible

Without structured review of clinical records, organisations may overlook weaknesses in investigation follow-up, referral decisions or diagnostic documentation.

Medical record audits can help identify these gaps before they become recurring system-level problems.

What Does This Mean for Bangladesh?

The Swedish findings should not be treated as an estimate of diagnostic error in Bangladesh. Our health system has different resources, workloads, information systems and patterns of access to care.

However, the study raises questions that deserve investigation in Bangladeshi primary healthcare settings.

How consistently are clinical findings documented? Can clinicians access previous investigations? Are abnormal results followed up? Do patients understand when to return? Are referrals completed and communicated?

These are important questions for patient safety, particularly where records may be fragmented and access to specialist services is limited.

The priority should be to understand local gaps through evidence rather than assume that findings from another country apply directly to Bangladesh.

A Practical Agenda for Bangladesh

1. Policy level: Establish minimum standards for diagnostic safety

National primary healthcare policies should define essential clinical documentation requirements, including relevant history, examination findings, working diagnosis, important differential diagnoses, investigation plans and follow-up arrangements.

Policies should also establish clear responsibilities for communicating test results, tracking referrals and protecting patient information.

2. Management level: Introduce structured clinical record audits

Hospitals and primary care facilities should periodically review a sample of records using a standardised checklist.

Audits could assess:

• Completeness of clinically relevant documentation.
• Evidence of appropriate diagnostic reasoning.
• Follow-up of investigations and abnormal results.
• Clarity of referral and follow-up plans.
• Documentation of safety-netting advice where appropriate.

Findings should be discussed with clinical teams to identify system weaknesses and agree on practical improvements. The purpose should be learning and safer care—not simply assigning blame.

3. Frontline level: Strengthen everyday clinical practice

Clinicians should document relevant findings and reasoning, communicate investigation results clearly and explain when patients need reassessment.

Patients should understand what symptoms require urgent attention, what to do if their condition does not improve and how to access follow-up care.

Better documentation should not mean unnecessary paperwork. The goal is to record the information needed to support safe decisions and continuity of care.

4. Quality improvement level: Measure, test and learn

Selected primary care facilities could begin with a baseline audit, introduce a small improvement intervention and repeat measurement using Plan–Do–Study–Act (PDSA) cycles.

Possible indicators include:

• Percentage of records meeting agreed documentation standards.
• Percentage of abnormal test results with documented follow-up.
• Percentage of referrals with a documented plan and outcome.
• Percentage of patients with persistent symptoms who receive appropriate reassessment.

Targets should be based on local baseline data and clinical standards. Improvement should be evaluated over time rather than assumed from the introduction of a new form or checklist.

5. Digital health and AI: Support the clinical process

Electronic health records and clinical decision support systems may eventually help identify incomplete documentation, overdue investigations and patients who require follow-up.

However, digital tools should be introduced only when they address a clearly defined problem. They require appropriate data quality, local validation, privacy safeguards and clinical oversight.

Technology cannot compensate for unclear responsibilities or a weak follow-up system. It should strengthen well-designed clinical processes.

My Key Observation

The most important lesson is that diagnostic safety depends on more than reaching the correct diagnosis at a single consultation.

It also depends on how clinical reasoning is recorded, how uncertainty is managed, whether investigations are followed up and whether patients remain connected to care.

For Bangladesh, a practical starting point is not necessarily expensive technology. It is establishing clear standards, conducting structured audits, improving communication and building a culture in which clinical teams learn from gaps in care. However,

Better documentation is not about writing more. It is about making clinical reasoning visible, strengthening continuity and reducing preventable diagnostic risk.

The challenge for policymakers and healthcare leaders is to translate these principles into measurable improvements across primary healthcare.

How can Bangladesh establish a practical, sustainable approach to diagnostic safety and clinical documentation?

This article discusses the implications of published research and proposes quality improvement priorities for Bangladesh. The recommendations are not findings or effect estimates from the Swedish study.

References

Fernholm R, Kappelin C, Nemlander E. Documentation-related diagnostic safety concerns in primary care: a structured medical record review of 1116 patient records. BMJ Quality & Safety. 2026.

Read the original research article

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Quality Care Concern promotes evidence-informed discussion and practical approaches to healthcare quality, patient safety, clinical governance and health system improvement. The views presented here are intended to encourage learning, policy dialogue and locally relevant quality improvement.