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National Patient Safety Agency

Catheter mix-ups in NHS prompt new guidance

Thursday 30th April 2009


Today (30th April) nurses and other frontline healthcare staff are being alerted to the risks of accidentally inserting shorter-length urinary 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 urinary 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 urinary 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.






Notes to Editors:


Media enquiries to the NPSA Press Office:

Paul Cooney – 020 7927 9351 / paul.cooney@npsa.nhs.uk

Sara Coakley – 020 7927 9580 / sara.coakley@npsa.nhs.uk.

Urinary catheters are used for a range of clinical conditions where it is necessary to drain urine from the bladder when all other means of management have proved unsuccessful e.g. in some forms of surgery and patient immobility, to protect wounds, problematic incontinence or urine retention.


Adult urinary catheters are manufactured in two lengths: female length (20-26cm) and standard length (40-45cm). Female patients use shorter length catheters as they have shorter urethras. Also if they are mobile, shorter length catheters allow women to hide the device under their clothing more discretely. While female patients can use standard length catheters with no known safety risks, men cannot use female length ones as the ‘balloon’ part of the catheter that is inflated with sterile water to stop the device falling out, will still be in the urethra rather than the bladder. This can cause severe trauma to the urethra and retention (where urine is unable to flow out) which can in rare circumstances lead to renal failure.


Between 01/01/2006 and 17/12/2008, 114 incidents were reported to the NPSA where female-length urinary catheters were inserted into male patients, all of which appeared to cause significant pain, plus some haemorrhaging, penile swelling or retention. In January 2006 the MHRA was notified of a fatality partly related to haemorrhage following the insertion of a female-length urinary catheter in a male patient. For more information view the Rapid Response Report and Supporting Information.


Rapid Response Reports are one page-long notices which are based on evidence of harm to patients and identify clear actions for healthcare staff to reduce risks of recurrence. Since June 2007, 18 have been issued to NHS organisations in England and Wales.


The National Patient Safety Agency is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations.