Catheter Mix-ups In NHS Prompt New Guidance, UK

Main Category: Urology / Nephrology
Also Included In: Medical Devices / Diagnostics
Article Date: 05 May 2009 - 5:00 PDT

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Last week nurses and other frontline healthcare staff are being alerted to the risks of accidentally inserting shorter length catheters - intended for use only in female patients - into male patients. These catheters are thin, flexible plastic tubes inserted in the urethra to drain urine from the bladder.

The guidance comes from the National Patient Safety Agency (NPSA) after 114 incidents were reported between 2006-2008 where female length catheters (around 20cm shorter than standard length ones) were accidentally inserted into male patients. All of these incidents reportedly caused significant pain to the patient and many caused other symptoms such as adverse swelling of the penis, urinary retention and heavy bleeding.

The guidance is for all NHS and independent acute, mental health and primary care organisations in England and Wales on how they can avoid these errors.

Dr Kevin Cleary, Medical Director of the NPSA said:

"Although the 114 incidents that were reported to the NPSA over the last two years represent a very small proportion of catheterisations that occur on a daily basis, they still should not be happening as they can be easily prevented with simple measures.

"We are advising all healthcare organisations that carry out catheterisations to review their current supply systems and limit access to female length catheters where appropriate, such as on all-male hospital wards. For healthcare settings that have to store both types in the same area, we have produced warning notices and labels designed to attract the attention of staff so that they are constantly reminded of the potential risk to male patients. Organisations can download these from our website at no cost."

Healthcare organisations have until September 2009 to implement these recommendations after which regulatory action may be sanctioned.

Source
NHS

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