Safety alert issued on catheterisation

The guidance comes from the National Patient Safety Agency (NPSA) after three patients died and seven were severely harmed after the devices were incorrectly inserted. Suprapubic catheters are used to drain patients’ bladders when they are blocked or when a urinary catheter cannot be inserted. They may also be used in patients with spinal injuries or neurological conditions such as multiple sclerosis and for some undergoing surgery. Dr Kevin Cleary, medical director at the NPSA, said: “Although the procedure is relatively common and carried out in most hospitals, the risks are not always understood. The data we received between September 2005 and June 2009 concluded that, on occasions, this technique was conducted by staff without proper support, training or equipment. When errors do occur, it can lead to patients suffering internal bleeding or experiencing other complications. As we have seen through our reports, in the most extreme cases, patients have died.” One of the recommendations outlined in the Rapid Response Report is for clinicians to use ultrasound machines when inserting these suprapubic catheters. “This is to ensure urologists and other relevant staff can accurately navigate the drainage tube into the bladder without piercing the bowel. It is vital all relevant staff are aware of how to use these machines when carrying out this procedure,” Dr Cleary added. The British Association of Urological Surgeons (BAUS) is currently developing national guidelines, which will provide more detailed information on best practice for clinical staff. Derek Fawcett, president of the British Association of Urological Surgeons, welcomed the latest advice from the NPSA: “Suprapubic catheterisation is an essential part of urological practice and this report serves as a timely reminder of the potential dangers. When used by experienced practitioners, it remains a safe way of helping some patients after bladder operations and in relieving distressing urinary difficulties.”