The UK National Health Service’s National Patient Safety Agency published a report entitled Minimising risks of suprapubic catheter insertion ‘, reporting three incidents of death and seven causing severe harm from suprapubic catheter placement between September 2005 and June 2009, nine of which involved bowel perforation. There were also 249 other incidents reported relating to suprapubic catheters causing lesser degrees of harm. They issue the following recommendations under the title ‘For IMMEDIATE ACTION by medical directors in acute and community hospitals (NHS and Independent Sector). Deadline for ACTION COMPLETE is 29 April 2010’:
- Information about the risk of this procedure is immediately distributed to all staff who may insert or request the insertion of a suprapubic catheter.
- A named lead for training is identified and a training plan developed.
- Local guidelines/policies are reviewed or developed in the light of this report and forthcoming British Association of Urological Surgeons (BAUS) standards.
- Ultrasound is used wherever possible to visualise the bladder and guide the insertion of the catheter. There should be ultrasound machines available in the relevant areas and staff trained in their use.
- Local incident data relating to suprapubic catheterisation is reviewed, appropriate action is taken and staff are encouraged to report further incidents and to take part in the BAUS national clinical audit.