When a patient seeks medical attention following a head injury, the severity of the head injury is assessed and a clinical decision is made as to whether a patient needs to be admitted for either treatment, or for a period of medical observation. If admission to hospital is not required, the patient is sent home with advice to return if their symptoms worsen, or do not resolve. This is known as safety-netting advice (Silverston, 2016). It is essential for safe practice that clinicians know how to give appropriate safety-netting advice correctly, as not providing the correct advice to patients may result in a patient not recognising the need to seek medical attention when it is required. In practice, safety-netting is employed to help manage diagnostic uncertainty safely and to reduce the risk of harm to patients from errors in diagnosis, failures in treatment and from the unpredictable, serious complications that can occur during the course of what are normally minor illnesses (Silverston, 2014a).
The fundamental principle that underpins the need to provide safety-netting advice is that illness is a dynamic process (Neighbour, 2004). The relationship between illness, time and clinical assessment is such that the clinical findings that are required to establish the correct diagnosis may not yet have developed when the patient is first assessed, and therefore the first diagnosis that is made may not be the correct one (Silverston, 2014b). In addition, there is always the potential for a complication to occur that would require a change in the course of action for the patient. It is important that both clinicians and patients understand that the purpose of safety-netting advice is to help prepare the patient for the possibility that the patient's condition and their diagnosis may change over time, as the symptoms and signs of the illness change. This is why is it necessary to ensure that safety-netting advice is symptom-based and patient safety-focused.
Safety-netting
The first step in safety-netting involves a formal, holistic assessment of whether it is appropriate to send the patient home to monitor themselves, rather than arranging for the patient to undergo a period of medical observation, or for a medical review of the patient to be performed. A risk assessment tool, ‘The 5-C's’, has been developed to help facilitate this (Silverston, 2014c). Once it has been established that it is safe for the patient to monitor themselves or be monitored by a relative, the basic principles of safety-netting can be applied to the advice that is given. These principles that a medical re-assessment of the patient is required if the existing symptoms worsen, new symptoms develop, or if there is a general deterioration in their condition. A patient should also return if their existing symptoms do not resolve within a set period of time, or if the patient/relatives are concerned about the course of the illness. Advice should be given as to what should be monitored, how this should be done and how frequently. Finally, advice should be given on the specific criteria for seeking medical attention, along with how to seek help and how rapidly this should be done. The delivery of safety-netting advice should be patient-centred to ensure that the patient truly understands and appreciates why it is important to follow this advice, as well as the information that is being given (Silverston, 2016).
In order to provide patients with the right advice, the medical content of that advice needs to be carefully considered, along with the specific criteria that should mandate the patient seeking medical attention. This is a relatively straightforward process in someone with an isolated head injury, as the criteria for re-attendance all relate to changes in the patient's neurological state, or neurological symptoms. Delivering safety-netting advice becomes much more challenging when there are many potential complications of a medical injury and they involve different body systems, or when the patient is presenting with a non-specific symptom and the diagnosis is uncertain when the patient is initially assessed. For example, a child with a streptococcal sore throat may develop a local complication, such as a quinsy; a distant complication, such as meningitis, pneumonia, endocarditis, or glomerulonephritis; or a systemic complication, such as sepsis. On the other hand, a child with a sore throat due to glandular fever may develop an entirely different set of complications, requiring different safety-netting advice to be given.
Safety-netting advice for a child with a non-specific symptom, such as a fever, becomes even more challenging, as the pathway that the illness may take will depend on a multitude of different factors, including the focus of the infection and the organism involved. Safety-netting advice for the risk of invasive meningococcal disease (IMD) has tended to dominate the advice that is given for children with a fever and this advice has often focused on parents checking for very specific findings, such as a non-blanching rash. However, there are other serious causes of a fever in children and not all children with IMD develop a non-blanching rash. As a result, there have been cases where parents have not sought help when other symptoms and signs of serious illness, including IMD, have developed in their children. This highlights the importance of ensuring that all safety-netting advice contains the correct medical information, as patients and parents may not be aware of the significance of some symptoms and signs unless these are discussed with them.
‘Safety-netting advice should be patientcentred to ensure that the patient truly understands and appreciates why it is important to follow this advice’
The SAFER Approach
This article describes a mnemonic, SAFER, that has been used in other forms to bring a symptom-based, patient safety-focused approach to the prevention and detection of diagnostic errors (Silverston, 2019). Safety-netting advice that involves simply saying to the patient ‘come back if things get worse’, or ‘come back if things don't get better’, places patients at risk of serious harm because it relies upon the patient recognising the early warning symptoms and signs of serious illness without the patient being made aware of exactly what these are. Setting specific criteria for the patient's return enables the patient or relative to check for these specific red flag early warning symptoms and signs, rather than remaining focused on the presenting symptom, or calling for help too late when a general deterioration in the patient's condition has occurred.
SAFER Safety-Netting
The S in the SAFER mnemonic (see Box 1) refers to the need to consider the most serious causes or complications of a particular symptom or condition, as these involve the greatest risk of serious harm to patients. Given that there are approximately 250 main symptoms and 12 500 medical conditions, it is difficult to cover all the potential causes of a symptom or all the potential complications, so it is important to concentrate on those that result in the most serious harm to patients in the shortest possible time. This is especially true when there may not be an opportunity for the patient to seek help again unless the illness is detected in its early stages. The most commonly misdiagnosed medical conditions resulting in serious harm to patients involve three disease processes: cancer, infections and vascular events. It is important to consider the potential for these when formulating safety-netting advice (Newman-Toker, 2019). These conditions are often not diagnosed initially because they have presented too early for a firm diagnosis to be made, or because they have presented in an atypical form, or in an atypical patient.
Box 1.SAFER mnemonic
- S = What serious causes and complications do I need to make the patient aware of?
- A = What alternative diagnoses do I need to make the patient aware of?
- F = What specific findings do I need to make the patient aware of that would mandate the need for a medical re-assessment?
- E = What early/atypical presentations of serious illnesses do I need to make the patient aware of?
- R = What red flag symptoms and signs do I need to make the patient aware of?
Box 2.The 5-C's approach
- Is the patient capable of checking for the criteria that determine the need for a medical re-assessment, or is medical review required?
- Is the patient mentally, physically and medico-legally competent to assess and monitor themselves, or someone else?
- Can the patient comply with the advice and instructions that you are providing, practically & logistically?
- Can the patient comprehend the advice and instructions that you are providing?
- Have you confirmed that the patient has fully understood and appreciated the significance of your advice?
Source: Silverston, 2014c
The next step is to consider the medical information that will help patients to identify these serious illnesses. Patients will need to be made aware of those symptoms and signs that indicate the presence of these serious illnesses in both their early and established forms. The head injury advice sheet (NICE, 2014) is a good example of this principle in action, as it asks patients and relatives to check for the earliest warning signs that would indicate that the patient's condition is deteriorating, and not just those that develop later in the process. Patients and relatives may not be able to take a set of observations, or perform a detailed clinical examination, so it is necessary to think about those parts of the clinical assessment that they can perform and to focus the advice on a lay assessment of those symptoms and signs. For example, in sepsis, parents are often aware of the child having an increased thirst, laboured breathing, or the symptoms and signs of peripheral shut down, but may not recognise the significance of these compensatory mechanisms as they develop and may only recognise the seriousness of the child's condition when the child begins to decompensate (Thompson et al, 2006). In the absence of being able to perform a medical assessment of their child, it is important that they are made aware of those findings that they can monitor and respond to themselves.
There is also a need for the clinician to apply critical thinking to their medical knowledge in terms of considering what other, alternative diagnoses, the A in the SAFER mnemonic, have not been completely excluded at this point in time, so that patients can be made aware of the symptoms and signs of these, too. It is not uncommon for diagnostic uncertainty to exist after the initial assessment of the patient, as it may be necessary to wait for the results of tests and investigations before a firm diagnosis can be made, or it may be necessary to use time as a diagnostic tool (Silverston et al, 2014). Patients become more engaged in safety-netting when they understand the diagnostic process and the relationship between symptoms, time and clinical assessment in establishing the correct diagnosis.
Another area where critical thinking is particularly important is in thinking about the specific findings, the F in the SAFER mnemonic, that would mandate the patient requiring a further medical re-assessment of their symptoms and a review of the diagnosis. This should not only include specific red flag findings but also those findings that would not fit with a normal pattern of a minor illness, as these are often the first findings that can alert patients and relatives to the development of a serious illness. This is particularly important given that it may be easier for a lay person to identify what is not ‘normal’ about this episode of illness, than it is to identify a specific finding for a serious illness, as this may require the knowledge, skills and experience of a clinician to diagnose. These steps refer to the E and R in the SAFER mnemonic
Conclusion
Errors in diagnosis and diagnostic uncertainty are both relatively common in primary care and safety-netting is one of the most important strategies that is available to clinicians for reducing the risk of serious harm to patients from these events (Almond et al, 2009). However, for safety-netting advice to be of medical value to the patient, it is necessary to give careful consideration to the clinical content of the advice that is provided. The mnemonic, SAFER, is designed to help clinicians think about the clinical content of the safety-netting advice that they deliver to patients, both verbally and in writing. Patients require this clinical information to make informed decisions about when to seek a medical re-assessment of their symptoms and a review of the diagnosis. Safety-netting advice that does not provide the patient with this vital information may lead to an unnecessary delay in the correct diagnosis being made and the correct treatment being administered to the patient. It is not just best practice to provide the correct safety-netting advice, it is also SAFER practice.
Key Points
- Safety-netting advice is essential for safe practice to manage the risks of diagnostic uncertainty, diagnostic error, treatment failure and the unpredictable complications of minor illnesses.
- The medical content of safety-netting advice must be symptom-based and patient safety-focused.
- Specific criteria must be covered that would mandate the patient returning for a medical re-assessment of their symptoms and their diagnosis.
- The mnemonic, SAFER, can be used to help clinicians develop the medical content of the advice that they deliver and set the specific criteria for the patient returning for a medical re-assessment.
CPD reflective questions
- Why is it necessary for safe practice to provide every patient with appropriate safety-netting advice at the end of each consultation?
- What are the key components of good safety-netting advice?
- Why is it necessary to consider the medical content of safety-netting advice?
- How will you incorporate the mnemonic SAFER into the safety-netting advice that you give your patients?