The TOS study: can we use our patients to help improve clinical assessment?

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.