Medical errors in primary care clinics – a cross sectional study
Open accessAbstract
BACKGROUND: Patient safety is vital in patient care. There is a lack of studies on medical errors in primary care settings. The aim of the study is to determine the extent of diagnostic inaccuracies and management errors in public funded primary care clinics. METHODS: This was a cross-sectional study conducted in twelve public funded primary care clinics in Malaysia. A total of 1753 medical records were randomly selected in 12 primary care clinics in 2007 and were reviewed by trained family physicians for diagnostic, management and documentation errors, potential errors causing serious harm and likelihood of preventability of such errors. RESULTS: The majority of patient encounters (81%) were with medical assistants. Diagnostic errors were present in 3.6% (95% CI: 2.2, 5.0) of medical records and management errors in 53.2% (95% CI: 46.3, 60.2). For management errors, medication errors were present in 41.1% (95% CI: 35.8, 46.4) of records, investigation errors in 21.7% (95% CI: 16.5, 26.8) and decision making errors in 14.5% (95% CI: 10.8, 18.2). A total of 39.9% (95% CI: 33.1, 46.7) of these errors had the potential to cause serious harm. Problems of documentation including illegible handwriting were found in 98.0% (95% CI: 97.0, 99.1) of records. Nearly all errors (93.5%) detected were considered preventable. CONCLUSIONS: The occurrence of medical errors was high in primary care clinics particularly with documentation and medication errors. Nearly all were preventable. Remedial intervention addressing completeness of documentation and prescriptions are likely to yield reduction of errors.
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Variability in the quality of documentation can impact patient outcomes and continuity of care.
“Moreover, the variability in the quality of documentation—ranging from omissions of critical details to inconsistent formatting—can impact patient outcomes and continuity of care [10, 11].”
From Artificial Intelligence (AI) – Powered Documentation Systems in Healthcare: A Systematic Review (2025) · cites this paper as [10]
The Results (Documentation errors; page not provided) document frequent omissions, and the Conclusion says more complete documentation is likely to reduce errors and improve patient safety. The paper does not address continuity of care or identify inconsistent formatting as a documentation problem; it discusses illegible handwriting instead. (LLM, conf=0.84)
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Hwong, W. Y., Ng, S. W., Tong, S. F., Ab Rahman, N., Law, W. C., Wong, S. K., Puvanarajah, S. D., Mohd Norzi, A., Lian, F. S., & Sivasampu, S. (2024) · Figshare · doi:10.6084/m9.figshare.24953210
Additional file 1 of Regret among primary care physicians: a survey of diagnostic decisions
Müller, B. S., Donner-Banzhoff, N., Beyer, M., Haasenritter, J., Müller, A., & Seifart, C. (2020) · Figshare · doi:10.6084/m9.figshare.11998905
Best Practices for Diagnostic Excellence in Primary Care
Harada, Y., Watanuki, S., Aoki, T., Ito, M., Iyasu, A., Uehara, T., Ishimaru, H., Ashino, A., & Yamaguchi, A. (2025) · An Official Journal of the Japan Primary Care Association · doi:10.14442/generalist.48.141
- Authors
- Khoo, E. M., Lee, W. K., Sararaks, S., Abdul Samad, A., Liew, S. M., Cheong, A. T., Ibrahim, M. Y., Su, S. H., Mohd Hanafiah, A. N., Maskon, K., Ismail, R., & Hamid, M. A.
- Affiliations
- University of Malaya (MY)
- Ministry of Health (MY)
- Universiti Putra Malaysia (MY)
- Corresponding author
- Khoo, Ee Ming
- ORCID
- Venue
- BMC Family Practice
- Published
- 2012-12
- Volume
- 13
- Issue
- 1
- Pages
- 127-127
- ISSN
- 1471-2296 (ISSN-L)
- PMC
- PMC3565960
- OpenAlex
- W2027611417
- Cited by
- 78
- References
- 24
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 9 · 2023: 5 · 2022: 2 · 2021: 7 · 2020: 12 · 2019: 2 · 2018: 8 · 2017: 6 · 2016: 5 · 2015: 10 · 2014: 5 · 2013: 3
- FWCI
- 9.93
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Family Practice (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- The University of Malaya Research Repository (University of Malaya) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Greater South Information System
- Funders
- National Institutes of Health
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Keywords
- medical errors, patient safety, primary care, diagnostic errors, management errors, medication errors, documentation errors, handwriting legibility, preventable errors, Malaysia
- MeSH terms
- Ambulatory Care Facilities, Cross-Sectional Studies, Diagnostic Errors, Documentation, Humans, Malaysia, Medication Errors, Primary Health Care, Retrospective Studies, Medical Errors
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