Table 2

Reducing safety incidents in remote primary care

Clinical conditions for which an in-person assessment is often required.Acute chest or abdominal pain.
Breathing difficulties.
Breast lump.
Palliative care.
Physical injury.
New psychosis.
Diabetes reviews where eye or foot examination is needed.
Persistent or progressive skin lesion.
Acute history that does not make sense.
Clinical trajectories for which an in-person assessment is often required.Condition has not resolved as expected (or has progressed) after previous remote consultation(s).
Escalating parental concern.
Acute condition overlaid on pre-existing complex illness (including mental health).
Patient-level features that make remote assessment more difficult and suggest a lower threshold for defaulting to in person.Extremes of age.
Care home residents if on-site staff not confident to undertake observations.
Language non-concordance.
Relevant impairment (eg, deafness).
Conditions that may complicate communication (eg, autism).
Low health literacy or system literacy.
Lacks key technologies or the ability to use them.
Key features of effective safety netting.Make clear to patient what the next steps in their care are, what to do if things get worse and action to take if expected care (eg, a call-back) does not happen.
Make all points explicit; do not assume that the patient already knows.
Fully document what safety-netting advice has been given.
Back up verbal advice with text or email, including leaflet or web link if appropriate.
Avoid rigid protocols and overscripting (but if non-clinicians are giving safety-netting advice, consider some basic standard scripts).
Ask patient/family member/carer to repeat back safety-netting instructions.
Organisational and system-level measures.Adequate staffing and appropriate mix.
Optimise triage pathways and workflows for remote encounters.35 36 48 65
Protocol for times of extreme stress (staff absence, high demand).
Reduce distractions.19 20
Optimise relational continuity for complex and vulnerable patients (eg, elderly) and continuity of illness episode for all patients.41
Provide training for all staff (not just in the technology); train for capability (taking initiative, playing hunches).21 66
Encourage workarounds and purposively develop norms for flexible working.19
Advice directed at patients and carers.Think about how to describe your symptoms clearly before the appointment (write down key points if that helps you).
Think about whether you need to have someone with you when you have your remote appointment (eg, to help with the technology or with communication).
If you think an in-person consultation is needed, say so when you book the appointment and explain why. An in-person appointment is likely to be needed for:
  • Chest pain/shortness of breath.

  • Abdominal pain.

  • Injury caused by a fall or accident.

  • Unusual lump.

  • Urgent mental health problem.

  • Persistent skin problem.

  • A child or someone in care who is unwell.

  • If you have already had two remote appointments for a problem that is not improving.

Be sure to tell the clinician all the key points about the current problem, even if you have told someone else from the surgery beforehand. Mention other conditions that may be relevant—for example, diabetes, a heart or chest condition, or a mental health condition.
If you are very concerned about the problem, especially if things are getting worse, say so clearly.
Ask the clinician to explain what happens next after the appointment and what to do if your symptoms do not improve. If you would like them to explain something again (to you or the person helping you), ask.
Ask them to send you instructions (eg, via text message) if you would like this, and to include any further information such as a leaflet.