A Rapid Response Report by the National Patient Safety Agency outlines how catheter training, storage and labelling can prevent serious harm in men
Action to prevent errors
As every nurse is likely to insert a urethral catheter at some point, they need to be sure that they are using a catheter of the correct length.
Catheters are commonly used in acute care, in patients’ own homes, in social care and in nursing homes. They are manufactured in a range of different gauges and three lengths: female length (20-26cm), standard length (40-45cm) and paediatric (30-31cm).
The gender difference in urethral lengths means that, should the shorter female length catheter be used in males, the inflation of the balloon with water occurs within the male urethra rather than the bladder. This can cause severe urethral trauma and result in pain and haemorrhage, or longer term effects such as urethral strictures, retention or incontinence.
Clinical practice differs between healthcare settings. Some areas will stock only standard length catheters and use different gauges for male and female patients. In other areas, the use of shorter female length catheters, which have no clinical imperative, are used for patient dignity issues such as concealing catheters under skirts.
Between January 2006 and March 2009, the National Patient Safety Agency received 114 reports of serious harm from errors where shorter female catheters had been inserted in males. The result was a range of serious outcomes for the patients, including cases of acute renal failure or impaired renal function. Some patients required additional medical or surgical procedures to correct the trauma.
In April 2009, the NPSA issued a Rapid Response Report (RRR) on the risks of female catheters causing urethral trauma in men, with the aim of making practice safer.
Examples of actual incident reports:
- Patient catheterised on admission by staff nurse. No urine seen or drained over a few hours. A doctor informed and he was unable to remove the catheter or deflate the balloon. A urologist was then called, who deflated the balloon with a needle through the penis. Large clots were passed. The patient had been catheterised with a female catheter.
- Admitted patient had a female length catheter in male patient. The patient was admitted with acute renal failure. He was recatheterised with an appropriate catheter and conservatively managed. Renal function recovered.
- Patient presented to A&E with urine retention. He had had a female catheter fitted the previous day by his district nurse.
He said that she told him she had no male catheters and asked if he minded having a female one.Frances Wood, clinical reviewer, NPSA
Five ways to make practice safer in your hospital
1 Consider who needs to see the RRR
It should be available to all staff who catheterise male and female patients, including newly qualified staff. Raise awareness with student nurses and medical staff.
2 Check your stock
Do you stock the shorter female length for patient choice or because of local custom and practice? Reduce potential for confusion by ordering and stocking only standard length catheters where possible.
3 Reduce the risk of confusion
Where both shorter and standard lengths are in use, ensure that they are clearly labelled. Consider storing them in different areas of the stock room.
4 Be alert to signs and symptoms after catheterising males
Are they in pain, passing blood or unable to pass urine? Could this be because a catheter of the wrong length has been fitted?
5 Consider whether your organisation is compliant
So far, 96% of organisations have reported compliance with the RRR deadline of September 2009. Discuss any potential problems with your line manager.
What should my trust be doing?
The NPSA Rapid Response Report identified key actions to make practice safer.
Find out if these are being put into practice:
- Distribute the RRR to all staff who insert urinary catheters in teenage or adult male patients, and to pharmacists who dispense them.
- Review supply systems for female length catheters, with the aim of limiting access where appropriate.
- Display a warning notice close to the stock of female length catheters if teenage or adult males are treated in this clinical area.
- Ensure additional clear warning labels are attached to each catheter before distribution to clinical areas or community staff bases where both men and women are treated (See http://tinyurl.com/RRR‑catheter to download labels and for steps on safe labeling)
- Review local competency based training for urinary catheter insertion to ensure it includes selecting catheters of the correct length.
How to use the Rapid Response Report to change practice
A serious incident involving the insertion of a female catheter into a male patient led one trust to review its implementation of the Rapid Response Report (RRR) recommendations, resulting in safer practice and training.
“The trust is very proactive and keen on learning from mistakes, so we always share serious incidents. If it was an issue for us, it will be for others,” says Michelle Woodward, senior risk and litigation manager at Northampton General Hospital Trust.
“At the time of the serious incident, we had already gone ahead and complied with the RRR by displaying the warning posters provided.
“But, while the poster highlighted selecting the right size, many staff are trained to focus on male versus female. Where different lengths were stocked together, these warnings should have been clearer, with additional warning labels attached.
“Another factor was nursing staff collecting items for medical staff. Now we don’t just segregate but recommend completely separate rooms or storage areas. We also limit the supply of female catheters to specific wards and departments such as gynaecology.
“In addition to the posters provided with the RRR, we have developed large warning notices ourselves and encourage all staff to collect their own catheters whenever possible – and ensure that they always double-check both the length and the type. We also undertook a full review and asked staff what would help them, and fed back to the NPSA including advising colour coding for packaging in the future.
“Each RRR includes a link to an immense amount of evidence based background information. This helps staff pick up on priority safety issues.
“For example, we discovered that the local training programme for medical staff didn’t significantly focus on risk prevention but mainly on technique. We were able to feed that back to the deanery so that this could be emphasised in training for all staff.
“We also highlighted the importance of correct supervision of medical staff during catheterisation. This has increased awareness and resulted in a greater uptake of our local catheterisation refresher training.
“What is good about this RRR is its emphasis on equipment storage in relation to patient safety. This backs up the work of our service improvement team and a local nursing initiative relating to the LEAN programme – all leading us to consider the design of the wards and storage areas when reflecting on serious incidents.”
Every reported incident counts
Each serious incident you report is reviewed at the NPSA. We see if there is potential for national action (an RRR) by looking for further evidence of harm in our database of more than four million incidents reported by nurses, doctors and others. Each RRR starts with a single incident – in this case, a female catheter used in error.
Please carry on reporting to ensure safer care.
Did you know?
- Insertion of female length catheters in males is rare in proportion to the high numbers of catheters inserted annually, but, when it happens, it always results in harm.
- Ordering and stocking only standard catheter types is the strongest barrier to prevent harm from this type of error. Some hospitals have successfully implemented a strategy of restricting access to female length catheters.
- Clinically, it is not necessary to use a shorter female length catheter, but women wearing skirts may prefer them.
- Standard length catheters are usually 40-45cm long, while shorter length female catheters measure 20-26cm. Be aware that shorter length catheters are sometimes placed in packaging of the same type as standard catheters.
- Packaging, while compliant with EU regulations, may not prevent harm – the word “female” may be in very small type. One manufacturer attaches NPSA warning labels to its products at source and further design solutions are needed. Meantime, you should apply NPSA labels to catheter packaging locally.
- Errors are made by hospital nurses and doctors, community nurses and GPs, and by ambulance and nursing home staff.
Find the Rapid Response Report, additional information and downloadable warning posters and labels on the NPSA website at NPSA guidance.
- A PDF of this article as it appeared in Nursing Times is available above.