Clinical Notes : Medico-Legal

18. Diagnostic Safety-netting

The need for safety-netting

  • Missed diagnosis is inevitable

    • refer after repeated consultations for the same symptom where the diagnosis is uncertain three strikes and you are in

  • No diagnostic test or clinical decision is 100% sensitive

    • repeat tests and examinations even if negative on previous occasions

  • At an early stage classic ‘red-flag’ features of serious illness may be absent

    • e.g. 50% meningitis diagnosis is missed at first presentation as characteristic features of the illness are yet to appear

  • At first presentation, the serious complications of an usually uncomplicated illness may not have developed

    • e.g. dehydration in gastroenteritis or sub-dural haematoma after head injury.

 

When to safety-net

  • Uncertain diagnosis with a differential including serious illness that can progress rapidly

    • e.g. uncomplicated sepsis

  • Certain diagnosis with known risk of serious complications

    • eg cauda equina syndrome, head injury

  • Patient has an increased risk of complications

    • e.g. elderly, young children, co-morbidities

 

How to safety-net

  • Communicate clearly

  • State uncertainty clearly

    • e.g. You have sepsis. It can deteriorate quickly and if it does you will need admission to hospital....”

  • Pinpoint what to look out for (red flags)

    • e.g. “If you feel your heart beating faster, your breathing gets faster, you become more muddled, your temperature goes up or you get the shivers...”

  • Detail how to seek help

    • e.g. “If you feel your heart beating faster, your breathing gets faster, you become more muddled, your temperature goes up or you get the shivers...”

  • Arrange follow-up

    • either with own GP or at OOH service

  • Ensure that safety netting advice is understood

    • particularly by patients with language and literacy barriers

 

Record keeping :

Make  a  detailed record  of

  • safety-netting advivce provided

  • red flags discussed

  • advice given re how to seek help

  • follow-up arrangements

 
 
 
 
 

Almond S, Mant D, Thompson M

Diagnostic safety-netting

Br J Gen Pract. 2009 Nov 1; 59(568): 872–874.

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