Clinical Notes : Medico-Legal
18. Diagnostic Safety-netting

The need for safety-netting
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Missed diagnosis is inevitable
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refer after repeated consultations for the same symptom where the diagnosis is uncertain three strikes and you are in
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No diagnostic test or clinical decision is 100% sensitive
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repeat tests and examinations even if negative on previous occasions
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At an early stage classic ‘red-flag’ features of serious illness may be absent
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e.g. 50% meningitis diagnosis is missed at first presentation as characteristic features of the illness are yet to appear
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At first presentation, the serious complications of an usually uncomplicated illness may not have developed
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e.g. dehydration in gastroenteritis or sub-dural haematoma after head injury.
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When to safety-net
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Uncertain diagnosis with a differential including serious illness that can progress rapidly
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e.g. uncomplicated sepsis
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Certain diagnosis with known risk of serious complications
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eg cauda equina syndrome, head injury
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Patient has an increased risk of complications
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e.g. elderly, young children, co-morbidities
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How to safety-net
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Communicate clearly
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State uncertainty clearly
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e.g. You have sepsis. It can deteriorate quickly and if it does you will need admission to hospital....”
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Pinpoint what to look out for (red flags)
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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...”
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Detail how to seek help
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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...”
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Arrange follow-up
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either with own GP or at OOH service
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Ensure that safety netting advice is understood
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particularly by patients with language and literacy barriers
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Record keeping :
Make a detailed record of
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safety-netting advivce provided
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red flags discussed
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advice given re how to seek help
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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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