Diagnostic safety-netting

Clinical Notes : Medico-Legal

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