Safety netting

A REVIEW of MDDUS cases reveals a certain inevitability surrounding some missed diagnoses in medicine. Patients present at different stages of their illness and red flag signs and symptoms may be absent, or do not present until later on. Safety netting is a diagnostic strategy or consultation technique to effect timely re-appraisal of a patient's condition.

The term "safety netting" was first introduced by Roger Neighbour in The Inner Consultation (1987). He considered it a core component of GP consultations and defined the term from a clinician’s perspective as encompassing three questions:

• If I'm right what do I expect to happen?
• How will I know if I'm wrong?
• What would I do then?

From a risk management perspective, it is essential to have safety-netting procedures in place – for example to advise patients of particular symptoms that they should alert their doctor to, if these develop. At its core is a requirement to provide sufficient advice in the event of any deterioration, by devising a management plan which can be understood by the patient and putting a safety net in place should things not go as expected. The patient should be left in no doubt of the importance to seek urgent help should there be any serious deterioration in their condition or if they become concerned.

Once a history has been obtained, examination performed and an explanation provided, it is vital that the patient understands what to expect, and the implications of any red flag symptoms.

What should safety net advice include?

• Explain uncertainty to the patient. If the diagnosis is uncertain, this should be communicated to the patient so that they are aware to re-consult if necessary. Patients are often seen extremely early on in the illness process and some symptoms may be medically unexplained following initial assessment. If the aetiology is uncertain, explain this to the patient.
• Highlight things to look out for. If there is a recognised risk of deterioration or complications developing then the safety-net advice should include the specific clinical features that the patient should look out for. Patient information leaflets can be valuable in supporting this. It can be beneficial to gain an understanding of what the patient's thoughts and concerns are around their symptoms, in order to avoid a potential mismatch of doctor and patient agenda.
• Signpost further help. Give the patient specific guidance on how and where to seek further help if required. This may be as simple as booking a return appointment.
• Map out a timeline. Where the likely time course of illness is anticipated, safety-net advice should include this information. However, it should be made clear that if a patient has concerns they should not delay seeking further medical advice. Providing a realistic time frame may prevent unnecessary consulting for similar future symptoms, thus empowering and educating patients.
• Check the patient has understood. Ask the patient to repeat what you have agreed, so that you are able to check their understanding.
• Keep accurate and detailed records. The safety-netting advice given should be documented within the patient’s consultation notes.

Safety-netting most often goes wrong when either it has not been given, particularly in high-risk situations, or it has not been properly heard or understood by the patient, or is insufficiently specific about what to look out for and what to do.

Many doctors give generic safety-net advice at the end of consultations (for example: "come back and see me if you're not feeling better") but do we really understand what this means to patients?

We know from our case files that inappropriate reassurance from a doctor that symptoms are not serious can lead to catastrophic delays in diagnosis and treatment. However, a downside of safety-netting can be to cause unnecessary additional anxiety.

While it is important for general wellbeing that GPs continue to appropriately reassure the vast majority of patients who are well, safety-netting does not remove the responsibility for diagnostic decision making by passing uncertainty onto patients.* Indeed, safety netting should always be viewed as a positive component of the patient consultation process to reduce the likelihood of preventable harm occurring.

Alan Frame is a risk adviser at MDDUS

* Almond S, Mant D and Thompson T. Diagnostic safety-netting. British Journal of General Practice 2009.