title: The TOS study: can we use our patients to help improve clinical assessment?
abstract: BACKGROUND
  We believe that there is a need to increase awareness, particularly among foundation year doctors, of the importance of performing a full neurological examination, including ophthalmoscopy, in medical inpatients. Following a serious unexpected incident (missed papilloedema), we implemented a multifaceted intervention, including ensuring greater availability of equipment for neurological/ ophthalmological assessment, education and curriculum redesign in two large teaching hospitals in the UK.
  
  
  METHODS
  Following the results of our initial intervention, we introduced a patient assessment scoring system to evaluate patient recollection of the completeness of neurological examination by medical staff in the two Trusts over a four-month period.
  
  
  RESULTS
  Of the 93 patients referred to neurology during this period, 33% could not recollect being examined with a tendon hammer and 48% said they had not been examined with an ophthalmoscope. In contrast, the majority (95.7%) remembered the use of a stethoscope in their examination. The data were fed back to medical staff which resulted in greater awareness of the importance of a complete neurological examination. No further adverse incidents of missed papilloedema were reported in the following 12 months, although it would be premature to state that this situation has been resolved.
  
  
  CONCLUSIONS
  A patient assessment score can be used by medical staff to raise awareness of the importance of a complete neurological examination from referring physicians.
authors.affiliation: The Department of Neurology, City Hospital, Birmingham B18 7QH, UK. David.nicholl@nhs.net
authors.forename: D J
authors.initials: DJ
authors.lastname: Nicholl
authors.forename: C P
authors.initials: CP
authors.lastname: Yap
authors.forename: V
authors.initials: V
authors.lastname: Cahill
authors.forename: J
authors.initials: J
authors.lastname: Appleton
authors.forename: E
authors.initials: E
authors.lastname: Willetts
authors.forename: S
authors.initials: S
authors.lastname: Sturman
mesh_terms: D000328:Adult; D001364:Awareness; D002983:Clinical Competence / Q000592:standards*; D057210:Delayed Diagnosis / Q000517:prevention & control*; D005260:Female; D019538:Health Care Surveys; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D011939:Mental Recall; D020380:Needs Assessment; D009462:Neurology; D009885:Ophthalmology; D009887:Ophthalmoscopy / Q000379:methods / Q000706:statistics & numerical data; D009901:Optic Nerve Diseases / Q000175:diagnosis*; D010358:Patient Participation; D010361:Patients; D010808:Physical Examination / Q000379:methods / Q000592:standards*; D010820:Physicians; D058996:Quality Improvement; D006113:United Kingdom; D055815:Young Adult