This Rapid Response Report alerts healthcare organisations to the risks of intestinal injury and bowel perforation following incorrect placement of suprapubic catheters in adults.
Suprapubic catheterisation should be used when urethral catheterisation is contraindicated or where it is technically not possible to relieve urinary retention in both acute and chronic conditions. In addition, it may be chosen to improve patient comfort, dignity or convenience, and to prevent complications such as catheter-induced urethral injury.
The Reporting and Learning System has identified 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.
NHS and independent acute and community hospitals should:
- Immediately distribute information about the risk of this procedure to all staff who may insert or request the insertion of a suprapubic catheter
- Identify a named lead for training and develop a training plan
- Review or develop local guidelines/policies in the light of this report and forthcoming standards
- Use ultrasound wherever possible to visualise the bladder and guide the insertion of the catheter
- Review local incident data and take appropriate action, and encourage staff to report further incidents