Safety netting is a management strategy used when diagnosis is uncertain. It ensures that patients are monitored until their symptoms resolve or diagnosis is confirmed by symptoms being explained and acted upon. As such, safety netting can help to reduce the occurrence of missed diagnosis and is now considered an important part of primary care consultations 🏨. In this article we will explain what safety netting is, how to do it, the important aspects you need to know about and what needs to be done when implementing safety netting. Within each section you will find subsections each with helpful summary sections to help you retain the most important points❗

Contents:

1. An introduction to what safety netting is

2. How to safety net

3. Important aspects of safety netting

4. What needs to be done when implementing safety netting

An introduction to what safety netting is

 

In this section we will endeavour to explain what safety netting is, exploring what it is, who it is used for, when it is used, and why it is important. We will also discuss how safety netting can go wrong so you can avoid the common mistakes.

What is ‘safety-netting’❓

 In simple terms it is a safety net created by doctors in consultations to make sure the patient is safe in unforseen circumstances 🏨

 It was first described by Roger Neighbour who said that it involves answering the following 3 questions:

1. If I am correct, what do I expect to happen❓ E.g. symptoms resolve within 1 week 📅
2. How will I know that I was wrong❓ E.g. symptoms do not resolve within 1 week 📅
3. If I am wrong, what should I do❓ E.g. make an appointment to review the patient if the symptoms have not resolved within 1 week 📅

 Safety net details should be recorded in the patient’s medical notes 📃

 It can be given either in written format or verbally 📃

Summary:

Safety netting is when you give patient’s advice about what to do if different possibilities occur, meaning they know when it is important for them to seek medical attention and how to do so.

 

Why is safety netting important❓

 It avoids legal issues as the doctor is warning the patient that the situation could deteriorate

 Reduces incidence of miss diagnosis ⬇

 Increase early-diagnosis of cancer ⬆

 Safety netting puts more responsibility on the patient to look out for signs which the doctor may not be present to see 🏨

 It can also avoid the need to make unnecessary GP visits or take unnecessary medication etc. as the patient or parent/guardian knows what to look out for 👁

 Patients can present at a consultation at different stages of their illness, meaning that no diagnostic test or clinical decision is completely sensitive 💉

Summary:

Safety netting is important and it reduces the incidence of missed-diagnoses and avoids medico-legal issues.

 

When is Safety netting used❓

 Initial consultations

 Follow up consultations and tracking 🏨

 Consultations to review the same issue

 Diagnostics 💉

 Communicating with secondary care (hospitals) 🏨

 When cancer is suspected

 Annual leave/locum protocols

Summary:

Safety netting should be used in a range of scenarios including: initial consultations; follow-ups; reviews; diagnostics; secondary care communications; suspected cancer; locum and annual leave protocols.

 

Which patients is safety netting particularly important for❓

 Children 👧

 Acutely unwell patients

 Patients with multimorbidity

 Patients with mental health problems 🧠

 Patients with suspected cancer

Summary:

Safety netting is particularly important for: children, patients who are suspected to have cancer or who have mental health or acute illness or multi-morbidity.

How can safety netting go wrong❓

 If a doctor does not give the patient or parent/guardian a safety net, especially in high-risk situations

 If the patient or parent/guardian does not understand the advice or does not hear it 👂

 If the doctor is not clear enough about what to do or what to look for 👁

 It can cause the patient or parent/guardian to worry unnecessarily

Summary:

Forgetting to give a patient safety netting advice can be very dangerous as the patient may assume they are fine and not return for medical attention because they feel as though they are wasting your time. If you are not clear enough about the advice you are giving, patients are at risk of not understanding it fully or forgetting. You should be aware of the risk of safety netting causing patients undue anxiety.

 

How to safety net

 

In this section we will explain how safety netting is done, providing tips, information about what to include and how to improve etc.

How do you safety net❓

1. Tell the patient when they should be concerned 😰
2. Tell the patient when to come back for a review 🏨
3. Explain the safety net to the patient verbally and then give them written instructions 📃
4. Organise a follow up appointment during the consultation in which safety netting is discussed 🏨
5. Confirm patient contact details ✅
6. Update electronic safety netting software so you automatically receive reminders 💻

Summary:

Safety netting should include information about: when to be concerned; when to come back/seek medical attention; an explanation given orally and in written form; details about a follow-up appointment. You also need to confirm contact details and update any IT software.

Different types of safety netting:

 Symptoms: “come back if your symptoms persist for another 2 weeks”; you must give a timeline for the patient to follow; appropriate for minor concerns; it can be useful to give the patient written information; make sure the patient knows how to contact you to organise a review

 Diagnostics: “book an appointment with me within a fortnight after you receive your test results so we can discuss them”; this has the issue that the patient may not be able to get an appointment very quickly; make sure the patient knows how to book another appointment 💉

 Referrals: referrals are now made by e-referral or email, fax is no longer used for referrals; tracking systems should be used so administrators can check it  🏨

 Follow-up: patients are most likely to book a follow up if you give them an appointment slip; document follow up discussed in the patient’s notes; there is no electronic tracking or reminder however 📅

Summary:

You need to explain the symptoms the patient needs to look out for or what to do when they receive the results of the investigations. You should make referrals discussed by e-referral or email, and book follow-up appointments for the patient to make sure you can review them.

 

The safety netting steps:

 Initial consultation:

1. Review the patient’s medical notes before the consultation to familiarise yourself 📃
2. Explain the safety netting advice to the patient and give them written instructions 📃
3. Arrange a follow up appointment 🏨
4. Set a reminder for yourself about the follow up appointment 📅
5. Make sure the patient understands the advice and is aware of what to do and where to go ✅
6. Make sure contact details are correct for the patient ✅

 Several consultations about the same problem:

1. Perform investigations for recurring/unresolved problems 💉
2. Clearly devise a plan to follow up on the results of these investigations 📃

 Investigations process:

1. Do not rely on the patient calling up to obtain the results, implement a system to make sure they are contacted ❌
2. Make sure the patient knows how and when to chase results of the investigations ✅
3. Make sure urgent results are communicated to patients in a face to face or telephone consultation ✅
4. Record concerning results electronically 💻

 Communication with secondary care:

1. Convey urgent results by telephone 📱
2. Check local hospital pathology/radiology policy about communication of urgent results 🏨
3. Make sure new clinical colleagues have pathology codes set up to ensure results are sent to the correct place
4. Make sure cancer diagnoses and other diagnoses/treatment plans are communicated quickly ⌛

 Referral:

1. Explain to the patient what they can expect going forwards
2. Record cancer referrals electronically and recommend referrals are also done electronically 💻

 Follow up:

1. Make sure locum doctors record concerns electronically so colleagues can access them
2. Ask administrative staff to document their attempts to contact patients 💻
3. Make sure vulnerable patients are given more flexibility

 Locum doctors:

1. Call/write to patients who do not attend follow up appointment, explaining the need to 📱
2. Make sure locum doctors are equipped with ‘locum packs’ explaining how to refer patients and the relevant codes 💻
3. If you are on leave, make sure results/letters are also sent to another colleague
4. Make another colleague aware of any concerns you have and record these in medical notes

 Practice administration teams:

1. Ensure contact details for patients are correct ✅
2. Keep electronic systems up to date 💻

Summary:

Safety netting involves: initial consultation; several consultations about the same problem; the investigation process; primary care communicating with secondary care; referral; follow-up. If there is a locum doctor you need to implement systems to ensure no information is forgotten or lost and administrative staff should be sufficiently trained.

 

What advice should be given in a safety net❓

1. Uncertainty: if you are not 100% sure on the diagnosis, you should tell the patient so that they re-consult you or get a second opinion if necessary in the future. This avoids false reassurance ❌
2. What to look for: tell the patient what the red flag signs to look out for are so that they know when to seek medical care  🏨
3. Where to seek medical attention: tell them exactly where to go if they notice any of the signs you have warned them about. E.g. A & E  🏨
4. Time-frame: if you know the expected time course of an illness and its developments, you should include this in the safety net. If symptoms persist longer than expected it may be a red-flag ⌛
5. Organise a follow-up consultation: offer to make this appointment so that the patient does not have to, if you feel you will need to review them 📅
6. Primary care investigations: explain why you are doing the tests you carry out and how they will receive the results
7. Administration: make sure you have the correct contact details and update any IT systems to set reminders or plan appointments/tracking 💻

Summary:

When providing safety net advice, you must: be honest and explain that you are uncertain about the diagnosis; tell them what red flag symptoms to look out for; explain clearly how/where they should seek medical attention; the time-frame they should expect symptoms to last and should therefore seek medical care after; arrange a follow-up consultation to review them; tell them why you are doing each investigation; update administrative systems e.g. IT/electronic databases/calenders.

 

How to improve safety netting:

 Be clear and specific❗

 Emphasise the importance: of the safety net

 Be precise: say exactly what they need to look for; say exactly what to do if they notice the safety net signs; say the specific time frame expected ⌛

 Make sure the patient knows what they are looking for: and how to book appointments if they notice the relevant symptoms/signs 👁

 Utilise IT systems: to enable administrative staff to run automated checks on the actions completed or outstanding by patients e.g. will show a patient who has not attended an outpatient appointment within the recommended time-frame 💻

Summary:

It is vital that you are clear when giving safety netting advice, and giving the advice in written format can help the patient to remember it. Double check that the patient has understood what they have been told and utilise IT systems to improve efficiency of safety netting by setting up reminders.

 

When is diagnostic safety netting used❓

 Up to half of patients leave a GP consultation without a specific diagnosis

 The most important task in a consultation is to eliminate the suspicion of serious illness❗

 Regardless of a diagnosis, if the patient has increased risk of serious illness due to co-morbidity or age, safety netting is important

 If you are unsure what the exact diagnosis is and differential diagnosis includes serious illness, safety netting is very important

 Even if the diagnosis is certain, if it poses a risk of serious complications, you should also utilise safety netting

Summary:

When you are unable to give a definitive diagnosis in the initial consultation, you should provide safety netting advice so that the patient seeks medical attention if they develop any symptoms more indicative of the illness suspected.

 

Safety netting when cancer is suspected:

 Safety netting is a useful management strategy when cancer is suspected

 Cancer diagnosis in primary care settings is challenging because: the initial symptoms are non-specific; cancer occurs relatively infrequently; the clinical features evolve at different times in each case

 As a result, most cancer is diagnosed at a late stage

 Safety netting is a useful tool for diagnosing cancer sooner, after the initial consultation

1. Be prompt: when reviewing and taking actions after investigation results ⌛
2. Actively monitor low risk patients to assess changes in risk of cancer
3. Reassure concerned patients that their risk of having cancer is low if appropriate 🙂
4. Explain and offer written instructions of safety net so the patient knows what to look for and when to seek medical attention 📃
5. You may need to review patients with a symptoms associated with cancer but do not meet referral or further action criteria
6. You may need to review patients who develop new symptoms, or if their symptoms worsen/recur/persist
7. Use the electronic software available to make sure a patient is attending appointments for tests/investigations and organise a review with the patient 💻

 Low risk symptoms:

1. No investigation: provide the patient with education about the symptoms; assess their clinical history; monitor the patient ❌
2. Investigate in-house: run or request tests and trial treatment 🏨
3. Investigate at walk-in clinic or routine referral 🏨

 High risk symptoms:

1. Urgent referral (2 week wait): send reminders and make sure patient received and attended appointment 📅

Summary:

Cancer is one of the circumstances in which safety netting is most important due to the initial non-specific signs. You need to be prompt when taking any actions and actively monitor them. It is important to reassure the patient and clearly explain the safety netting advice before updating any databases necessary.High risk symptoms require you to urgently refer the patient, whereas you should decide whether low-risk symptoms warrant no/in-house/walk-in centre investigation.

 

What to tell patients:

 The usual time-course of their current symptoms ⌛

 When to return if symptoms persist beyond this and the importance of this, even if test results are negative 🏨

 Red flag symptoms to check for

 Information about a follow-up appointment 🏨

 The purpose of the tests they are having 💉

 The next steps e.g. how they will receive test results/appointments they need to attend

Summary:

Make sure you tell them how long you expect their symptoms to persist and when to return or seek help if they do not resolve. They also need to know what symptoms to look out for and the details of any follow-up appointments/next steps.

 

Top tips:

1. Give written instructions with the details of the safety net discussed 📃
2. No investigation is 100% sensitive, if you are concerned about a false negative result, repeat 💉
3. Utilise telephone appointments more, you can review their symptoms and then, if necessary invite them to a face to face consultation 📱
4. Use objective measures e.g. weight change, to alert you as one patient may complain at an earlier stage than another
5. Implement a robust system e.g. using electronic technology, to make sure the patient receives test results 💻
6. Implement robust systems to ensure vulnerable patients are supported e.g. by colleagues, when you are away from your practice
7. If you think a patient needs to be reviewed offer to make the appointment for them so they do not have to 🏨
8. Do not be worried that a referral may turn out to be unnecessary, it is better to be sure
9. Use reminders e.g. electronic, to remind you to follow up or check on the patient 📅
10. If notified about a patient missing an outpatient appointment, check why they were referred

Summary:

When giving a patient safety netting advice, it is really important to be clear and giving them the information in writing can help significantly. Implementing robust systems to ensure it runs smoothly is very important as it ensures no patient is forgotten thanks to automatic reminders for example.

  

Important aspects of safety netting

In this section we will explain some things it is important that you understand and are aware of before you begin safety netting.
 

Different methods of safety netting:

 Electronic: this is the recommended method: tasks (send to GPs/others); diary function (you can allocate tasks to a specific day in online diary dates); alert function (when you open a record you can see important information); text messaging (results/reminders); referrals (email references); pathology/imaging requests 💻

 Written: This is preferable to verbal safety netting; this includes writing this in the patient’s records or giving the patient a written plan about what to look out for, what to do and the expected time-frame; there is a risk that the paper can be lost however 📃

 Verbal: this is the least appropriate method of safety netting; it is appropriate if the level of concern is minor; you must be clear and specific, however, there is no way to check on patients if concerned 🗣

Summary:

The best method of saefty netting is electronic as it ensures paperwork is not lost, automatic reminders are sent and all information is accessible. Written safety netting is preferable to verbal as the patient has information to look back on.

 

Safety netting Read codes:

 Follow-up visit: 9N7B 🏨

 Follow-up appointment offered: 9n7M 📅

 Asked to come in to investigate results: 9N75 🏨

 Follow-up: 9c0H

 Follow-up arranged: 8H8 📅

 Patient asked to make an appointment: 9N7C

 Active monitoring: 9Ok4

Summary:

Read codes make up a thesaurus of clinical terms which provide a set of codes for clinicians to use when recording findings or procedures undertaken on IT systems.

 

Txt-netting:

 This is the act of using text messaging to safety net patients 📱

 Low cost and effective method of safety netting as it is an easy way to remind patients to come back when they are due to attend a review or follow-up consultation 💷

 E.g. for patients with low-risk potential cancer symptoms (common symptoms which rarely indicate cancer)

 This shows patients that the consultation will not be a waste of the doctor’s time and that they genuinely want to see the patient, as they have reached out 🏨

 This is a semi-automated process

Summary:

Txt-netting is the use of text messaging in safety netting. This is a cost effective, semi-automated process which helps to keep track of patients and remind them to come for follow-up consultations.

 

Recording safety netting advice:

 You should document safety net advice given in the patient’s medical notes 📃

 It is helpful to provide a written version of the safety net advice so that the patient has a record of it 📃

Summary:

You should record any safety netting advice you give a patient in their medical notes so you can look back on it. The patient will benefit from having a written version of the advice e.g. a leaflet.

 

 

What needs to be done when implementing safety netting

 

In this section we will explain what needs to be done before a doctor or an entire practice begins safety netting to ensure it is done properly and is a successful management strategy. 

What the GP needs to do:

 Make sure the patient understands the safety netting advice you have given them ✅

 If the test results are negative, follow-up with the patient until the symptoms resolve/are explained/referral is made, and consider the accuracy of the tests e.g. risk of false negatives

 If you are unable to diagnose a patient who has presented multiple times with the same problem, you may wish to refer them 🏨

 Use appropriate codes in IT systems for any action you take and set reminders up 💻

 Review and act upon any test results until the patient is referred/passed on to another doctor 🏨

 Detail the safety netting advice you give to the patient in their medical notes 📃

Summary:

As a GP, it is your responsibility to make sure the patient comprehends the safety netting advice you give them and make sure follow up and review them.

 

What the practice needs to do:

 Implement a system for telling patients about abnormal test results 📃

 Implement a system for telling patients who do not turn up for a follow-up consultation about abnormal test results 📃

 Implement a system to record the status of all test results to ensure they are all reviewed and acted upon

 Implement a system to ensure investigation ordered by locum doctors are followed up

 Implement a system to highlight repeat consultations for unexplained symptom

 Make sure you have up to date contact details for the patient ✅

 Tell the patient how they will receive their results

 Make sure all staff involved in result logging understand the importance of urgency 💻

 Hold learning events

 Perform an annual audit of new cancer diagnoses

Summary:

Your practice should implement systems to make sure no mistakes are made and that all clinicians implement safety netting in the same way.

 

Summary:

1. Safety netting is a management strategy used in primary care when diagnosis is uncertain. It encompasses the following questions: If I am correct, what do I expect to happen? How will I know that I was wrong?If I am wrong, what should I do?
2. You must tell the patient: about the uncertainty regarding diagnosis; the expected time-frame for their symptoms to persist; red flag symptoms; how to seek help if symptoms do not resolve or they notice any red flag symptoms; details about follow-up appointments
3. You should utilise electronic/IT systems and databases to make sure safety net information is accessible in the future and reminders are automatically sent about follow-up appointments