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Safety-netting in primary care

It is late in your Friday clinic. Your last patient is still on your mind. Some of their symptoms were potentially significant, but, on balance, you felt they did not meet the threshold to need immediate action or referral. You made a plan which felt OK at the time, but now you are worrying:

“What if I am wrong and the patient comes to harm as a result?”.

What steps could we take to maximise patient safety and minimise our concern?

In this article, we outline the role of safety-netting in managing risk and uncertainty in primary care; identify best practice; and look at steps we can take to mitigate any potential challenges in applying this model.

Safety-netting has been widely used in primary care since the 1980s, but very little formal research has taken place until more recently. In this article, we draw on a number of resources, attempting to quantify and ‘pin down’ this communication process and identify best practice in this area (BJGP 2009;59(568):872, BJGP 2018;69(678):e70, BMJ 2022;378:e069094, BMJ Qual & Safety 2022;31:541, BJGP 2025;75(751): 52).

This article was updated in May 2025.

What is safety-netting?

Primary care carries uncertainty. Missed diagnoses are an inevitable part of practice. No diagnostic test or clinical assessment can ever be 100% foolproof, and patients present at different stages in their disease. When seen at an early stage, a patient’s presentation may lack the recognised red flags or complications of the condition we ultimately diagnose. This uncertainty can trigger anxiety in both clinician and patient, and lead to risk of harm for patients and potential for complaint and litigation for clinicians.

Safety-netting is a consultation strategy we can use to manage our patients appropriately, while acknowledging the uncertainty that exists and keeping them safe. In general practice, safety-netting – a phrase coined by Roger Neighbour in his work on medical consultation skills (The Inner Consultation, Oxford: Radcliffe Publishing, 2004) – has been in use since the late 1980s.

Safety-netting involves the clinician giving specific advice to a patient about:

What to expect next in their condition, including a timescale to recovery.
What to do if this does not happen.
What are the red flags for urgent reassessment.

What safety-netting is not

Safety-netting is not generic advice such as “Do come back if concerned”, said over the shoulder as the patient leaves the room!

Why should we safety-net?

Illness is a dynamic process. Many presentations are self-limiting, and differentiating these from the early presentations of more serious or progressive conditions is not always possible. We cannot manage all patients as if the most severe potential illness was present. This would be harmful and unethical, risking overuse of antibiotics, overdiagnosis of incidental findings, unnecessary invasive tests and misuse of finite resources (BMJ 2016;355:i5515).

A 2022 BMJ Practice Pointer highlighted the difference that safety-netting can make to the patient clinical journey (BMJ 2022;378:e069094). Consider the following patients. At the time of initial presentation, the symptoms are indistinguishable. Each person has mild symptoms of what appears to be a self-limiting condition, and is given self-care advice. However, differing disease trajectories might lead to 4 very different outcomes:

When is safety-netting used?

We can use safety-netting (BJGP 2009;59(568):872):

When managing a condition where the diagnosis remains uncertain at the end of the consultation, and the differential diagnosis is potentially serious.
When managing a condition where the diagnosis is known, but it carries the potential of serious complication.
When managing a patient who has an increased risk of complication or severe illness (due to age or comorbidity).

How to safety-net

Roger Neighbour identified three key questions the clinician can ask themselves (The Inner Consultation, Oxford: Radcliffe Publishing, 2004):

If I’m right, what do I expect to happen?
How will I know if I’m wrong?
What would I do then?

A 2022 BMJ paper looked at prompts to consider when providing safety-net advice, using the mnemonic SAFER (BMJ 2022;378:e069094).

What might this look like in our consultation?

The ESP model of safety-netting

When giving safety-net advice, it should be empowering, specific and proportionate. The table below was developed by the Red Whale cancer course to distil recommendations taken from literature review, Practice Pointer and discussion articles in the BMJ and BJGP (BJGP 2019;69(689):e819, BJGP 2009;59(568):872, BJGP 2018;69(678):e70, BMJ 2022;378:e069094, BMJ Qual & Safety 2022;31:541).

Empowering	If the diagnosis is uncertain, we need to share this with our patient to empower them to reconsult if necessary. Give information in an appropriate manner for that individual. Avoid jargon. Consider what you can do to optimise understanding. Provide information in the appropriate written language/visual or other format. Signpost to additional resources and support. Actively check patient understanding and memory of information shared. If you have concerns that a person will struggle to retain or understand information sufficiently, or that they have the ability to follow your advice, ask whether there is anyone who can support them. Break information down into smaller chunks and provide visual aids if possible.
Specific	Use precise details to explain: Expected time course for the condition. Expected symptom progression. What to look for if the condition is not progressing as expected: Warning signs of deterioration or treatment failure. Demonstrate specific signs or tests they can check if appropriate. Consider using traffic light systems to prompt appropriate action if there is deterioration or failure to improve: Green: can self-care at home. Amber: primary care review. Red: emergency care review. How and where to seek further help if needed. Who will book follow-up? How will any test results be communicated? Leave an open door to return. Give clear advice that if a patient/parent/carer has concerns, they should not delay seeking further input.
Proportionate	It is important to balance the need to share uncertainty and potential outcomes with the risk of causing anxiety and obscuring the main message. In most cases, it is not appropriate to give a long list of all the potential outcomes, including worst case scenarios. We are not aiming to shed all responsibility for clinical decision-making. Share key facts succinctly and in an accessible manner, and document this. Sometimes, for instance where cancer or other serious illness is a significant potential diagnosis, more detailed discussion is required.

Additional considerations in safety-netting

Evidence from primary care shows that patients are more likely to follow safety-netting advice if the clinician showed they were aware of, and addressed, the patient’s concerns. This was particularly relevant if the patient was not already known to the clinician, was younger, or had previous missed diagnoses or difficult experiences with healthcare systems (BMJ Qual & Safety 2022;31:541). Individualising information increased relevance and usefulness.

There are a number of potential pitfalls in our practice systems, and we consider how to mitigate these now (BJGP 2025;75(751):52):

Potential pitfall	Mitigating actions
Record keeping	Good record keeping is a contractual and legal necessity. It is also useful as an aide-memoire for ourselves or our colleagues when caring for the patient in the future (BMJ Qual & Safety 2022;31:541). Keep accurate records which include objective physical observations. Use shared records so information can be seen by colleagues. Record notes of the specific safety-net advice given (e.g. a link to information leaflet).
Time constraint	We are all familiar with the stress of running late on a busy day! There is evidence that when more than one clinical problem has been discussed within a consultation, the patient is less likely to receive safety-netting advice. Use computerised templates to streamline documentation, but beware the importance of individual/contextual assessment. To avoid running out of time or forgetting, include safety-netting in management planning rather than to close the consultation. Consider using standardised leaflets or SMS messaging for rapid safety-netting and documentation. Share this risk with patients to help manage expectations of what can be achieved in a single consultation.
Communication breakdown, misunderstanding or misremembering	Be aware that when the patient/family has no prior experience of consulting with you and are in an unfamiliar setting, they may need additional time to build rapport so that they are more likely to trust you and follow advice ((BMJ Qual & Safety 2022;31:541). Use active listening and communication skills. Elicit patient concerns and expectations. Understanding their worries can help avoid misunderstanding of safety-netting advice. Use objective assessments and demonstrate these to patients/parents/carers (e.g. the NICE sepsis traffic light system). Provide written information (see below). Check whether patients can access text/online advice or need an alternative format.

Providing written advice

A 2025 network meta-analysis and an older 2015 systematic review looked at the value of adding written advice to our verbal messaging (BJGP 2025;75:e90, BMJ Open 2015;5:e008280). In short: we should do both.

Written safety-netting reduced antibiotic prescribing and reconsultation rates compared with usual care (BJGP 2025;75:e90.
Parents retained more knowledge about managing acute childhood illness when verbal and written information were provided together compared with written information alone (BMJ Open 2015;5:e008280).

Documentation of safety-netting

We all know that the busier we get and the more we are interrupted, the more difficult it is to make good contemporaneous notes. There is a longstanding mantra that whatever is said or takes place in a consultation, ‘if it isn’t written down/recorded, it didn’t happen’.

Here are 2 examples (dreamt up by the Red Whale clinical team!) of a plan recorded in clinical notes regarding a child presenting to out of hours with a temperature.

Example 1 URTI. Advice: see if worse.
Example 2 (with more detail) Parents advised that symptoms seem currently due to viral URTI and should resolve within 5–7 days. If temperature not settling, not able to drink/not passing urine/vomiting or parents concerned that condition is worsening, call to arrange same-day reassessment. If suddenly more unwell/abnormally difficult to rouse/pinprick non-blanching rash appears, attend ED immediately/call 999.

Although the consultation and what was actually said and done may have been identical, there is no proof of this. Importantly, the second example not only clarifies what was said, but, in medicolegal cases, is likely to be assumed to reflect a more thorough assessment and consultation.

Could artificial intelligence play a role?

Generative artificial intelligence tools may play a future role in facilitatating safety-netting advice and documentation (BJGP 2025;75(751):52). These tools have the potential to generate medical reports and advice in formats which are more accessible to patients, saving clinician time and enhancing patient safety. Watch this space! And always check information generated by AI for accuracy prior to giving it to your patient or adding it to clinical records.

Safety-netting in primary care

Safety-netting advice can help manage uncertainty and mitigate risks for patients.

Use the mnemonic SAFER to identify the information you need to share.

Give specific, accurate and proportionate information to empower the patient to seek further help if needed.

Document your safety-netting advice.

Useful resources:
Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge)
Resources for parents to back up verbal safety netting:

Healthier Together - safety-netting & parent information (option to text directly from the site to caregivers)

HANDi App

When Should I Worry? (available in 15 languages)

YouTube - NHS minor illnesses playlist

NHS – The Little Orange Book

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