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Table of Contents
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In a consultation, as well as the risk of diagnostic error, additional risks are involved in making decisions about managing a patient and risks related to the treatment provided.
In this article, we will look at how developing good safety netting skills (both verbal and written) can help you manage diagnostic risk safely and reduce the risk posed when deciding how to manage a patient.
You may be asked to demonstrate your safety-netting skills in an OSCE. In addition, as a clinician, providing safety netting advice is essential for safe practice.
What is safety netting advice?
In the emergency department and primary care, consultations often conclude with the patient being advised to seek medical care if the symptoms worsen or do not resolve.
Similarly, patients discharged from hospital are told to seek medical care if their condition worsens or they develop post-operative complications. This is known as safety-netting advice.
The first part of safety netting is ensuring it is medically appropriate and safe for the patient to return home and monitor themselves. In some circumstances, it may be safer to arrange for the patient to be reviewed and re-assessed or admitted to the hospital for the condition to be monitored and re-evaluated.
A comprehensive and holistic risk assessment must be performed when making this decision, during which a wide range of medical and non-medical factors must be considered.
For example, the ability of the patient to identify the early signs of a serious illness or complication will need to be considered, as well as their ability to care for themselves throughout their illness (e.g. if they live alone).
In some cases, it may be necessary to refer or admit a patient to hospital because they are at increased risk of developing a serious illness or complication or because they cannot care for themselves at home. As a junior clinician, you will encounter GPs referring a patient to hospital because of concerns about the ability of the patient to care for themselves at home during their illness. This must also be considered during the emergency department or ward discharge process.
How to give safety netting advice
You will often hear clinicians telling patients:
- “come back if it gets worse”
- “come back if it doesn’t get better”
- to return “if they are worried”
Whilst this is quick to perform and easy to remember, this form of safety-netting advice is of limited value to the patient.
Studies have shown that the quantity and quality of patient safety netting advice are very variable. Patients report that the advice they are given is often vague and unhelpful.
It is important to appreciate that patients depend on the quality of the information they are given to decide when and how they should seek medical care. Providing patients with inadequate safety netting advice may mean they either return too early (when medical care is not required) or too late (when treatment may be less effective).
Remember that providing patients with adequate safety netting advice ensures they return at the first sign that they are becoming seriously unwell. Treatment outcomes are better when treatment is started early. This explains why it is important for patients to be given high-quality safety netting advice, delivered in a way that they can understand and respond to.
The “6-Cs” for reducing decision-making risk
A systematic and holistic approach is required to ensure that all risk factors are considered when deciding when a patient should be referred, reviewed or sent home with safety-netting advice.
The “6-Cs” is a risk assessment tool that can help you evaluate the risks involved in making this decision.
- Criteria: are there any criteria for referral or review within the guidelines for that illness?
- Capable: can a layperson identify the amber and red flag findings?
- Care: can the patient care for themselves or be cared for by others at home?
- Comply: is the patient able to comply with your advice practically?
- Comprehend: is the patient able to comprehend and recall your advice?
- Confirm: have you confirmed that the patient has understood your advice and why it is important to follow it?
One of the ways that you can make your clinical decisions more objective, consistent and evidence-based is to refer to the decision-making criteria within the relevant NICE guideline for that symptom or condition.
For example, many of the guidelines tell you how to identify a patient who needs a referral to hospital or a medical review of their symptoms or condition. Consider whether a patient can recognise the findings that would indicate that they are developing a serious illness or complication or whether it requires someone with medical training and equipment to elicit or interpret these findings, in which case a medical review would be indicated.
The patient’s safety depends upon their ability to monitor their condition throughout the illness and respond to changes.
A patient who lives alone, or who is subject to periods of mental impairment due to alcohol or substance misuse, may be at risk of harm unless someone else is with them. For example, patients discharged following a head injury may deteriorate at home and be unable to recognise the need for help.
Patients dependent on others to care for them, such as children and older patients, are also at risk when they are unwell and subject to neglect or abuse.
The final part of the risk assessment relates to the ability of the patient to understand and follow the advice they are given. An assessment of the patient’s intellectual and language comprehension is required, along with their physical and logistical ability to follow the instructions that they are given. For example, if it is important to monitor the patient’s temperature, you need to know whether they can access a thermometer.
Communication is a two-way process, so it is important to check that the patient has understood what you have told them, correct any misunderstandings, and emphasise any important points again. If there are doubts the patient cannot comprehend or follow your advice, referring or reviewing the patient is safer.
Creating safety-netting advice
The first step in creating good safety-netting advice is to ensure that the medical content of that advice is correct.
Safety-netting advice contains a generic component that applies in all situations but also information that is specific to the patient’s symptom or condition, or the specific complication that they are at risk of developing later.
This is why the safety netting advice given to an adult with a minor head injury differs from that given to the parent of a child with a fever.
As treatment outcomes are generally linked to the point in the illness that treatment is initiated, it is essential that patients are informed of the earliest (amber flag) findings that would indicate that they are developing a serious illness or complication, as well as the later (red flag) findings.
The mnemonic SAFER can help create the amber and red flag findings that the patient needs to be informed of and the green flag findings that are consistent with the normal pattern of a minor illness.
- Serious (must-not-miss) causes: which “must-not-miss” serious illnesses and complications is this patient at risk of developing?
- Alternative (must-always-consider) causes: which “must-always-consider” alternative diagnoses is this patient at risk of developing
- Findings that do not fit with a minor illness or do fit with a serious illness: which findings do not fit with a minor illness, or do fit with a serious illness?
- Early & atypical presentations: which early and atypical presentations of serious illness need to be considered?
- Red & amber flag findings: what are the red, amber and green flag findings for these causes?
The next step is to create the patient content of the safety-netting advice. This involves translating the medical content into a language and form that patients can understand and follow.
Remember that patients may not understand medical terminology, so you will need to explain words and concepts in terms that your patient can understand. This will differ from patient to patient, depending upon a wide variety of factors, such as the patient’s intellectual and language ability and age.
It is worth practising safety netting with someone who does not have medical knowledge, as receiving feedback about this can help develop your safety-netting skills.
Organise the information
The final step is to organise the information so that a patient can access that information quickly and easily.
One way of achieving this is to create a traffic light action plan (green/amber/red) linking symptoms and signs to the response required from the patient.
The green section of the action plan refers to the symptoms and signs that the patient should expect to experience with a minor illness that is taking its normal course and a self-management plan.
The amber section features the signs and symptoms that indicate that the patient may be developing a serious illness or complication and that a re-assessment is required, along with how rapidly, where and how to seek medical care (e.g. ringing an advice line, making an appointment).
The red section contains the symptoms and signs indicating that the patient is seriously unwell and needs to seek medical care immediately, along with where and how to access this care (e.g. calling an ambulance or attending the emergency department).
Delivering safety netting advice
Verbal safety netting advice
Safety-netting advice must be delivered in a way that is patient-centred and patient-friendly. Coming to the consultation with a system for delivering safety netting will help reduce the risk of not providing patients with the key information they require for making decisions.
The mnemonic SBART can help you structure how you deliver verbal safety netting advice.
SBART mnemonic for verbal safety netting
- Explain what you have/have not found and the significance of these findings on the diagnosis
- Explain what you expect to happen if your diagnosis is correct (symptoms, signs, duration of the illness = Green flag findings)
- Explain why your diagnosis may be uncertain or incorrect (Diagnosis is based on what we find and findings can change over time.)
- Discuss any specific risks that the patient has (i.e. co-morbidities, medication, living alone)
Describe the assessments that the patient will need to do during their illness:
- What to check for (amber & red flags)
- How to check for these findings
- How often to check for these findings (day/night)
Describe the response required:
- How rapidly to respond
- Where to respond to
- How to respond
Traffic light action plans
- Green plan: normal pattern of minor illness & self-care plan
- Amber plan: symptoms & signs indicate that a serious illness or complication may be developing. Provide information on how rapidly, where and how to access medical care.
- Red plan: symptoms and signs indicate a need to seek medical care immediately. Provide information on how rapidly, where and how to access medical care.
Written safety netting advice
Support your verbal advice with written information or a link to an online trusted safety-netting resource.
It is important to remember that the patient recalls less than 40% of the information delivered during a consultation immediately following the consultation. Further memory decay is likely to occur once the patient gets home. In addition, the information provided during the consultation may not be passed on to others caring for the patient throughout their illness.
It is considered best practice to support verbally-delivered safety-netting advice with written safety-netting advice.
An advice sheet can be given to the patient or e-mailed during a remote consultation, or the patient can be referred to a trusted safety-netting advice website.
Traffic light action plans can be incorporated into safety-netting advice sheets to help patients access information quickly and easily. A good example is the advice sheet on fever in children under 5 years from Healthier Together.
The General Medical Council, medical indemnity organisations and professional bodies recognise the importance of providing patients with safety-netting advice. This emphasises the importance of developing good safety-netting skills.
Safety netting is particularly important in situations where a serious illness is included amongst the differential diagnoses being considered and when the patient is at increased risk of developing a serious complication of an illness.
The diagnostic process has significant limitations and imperfections; diagnostic uncertainty and incorrect diagnoses are relatively common. Providing patients with high-quality safety-netting advice helps us manage these risks more safely. It also protects patients and doctors from the consequences of incorrect diagnoses, decisions and patient management.
Dr Chris Jefferies
- Silverston, P. Why, when and how to give safety-netting advice. InnovAiT.
- Edwards, P. J., Silverston, P., Sprackman, J., & Roland, D. (2022). Safety-netting in the consultation. BMJ, 378.
- Silverston P. (2020). SAFER: A mnemonic to improve safety-netting advice. Practice Nursing, 31:1, 26-28.
- Healthier Together. Advice Sheets for children. Available from: [LINK]
- Northen Cancer Alliance. Safety netting in patients with cancer. Available from: [LINK]
- National Insititute for Health and Care Research. Safety-netting in general practice: how to manage uncertain diagnoses. Available from: [LINK]