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PERIOPERATIVE GRAND ROUNDS
Unseen Perils of Urinary Catheters
THE CASE
A 68-year-old man with a history of multiple comorbidities and health problems, including benign prostatic hyperplasia (BPH) with urinary retention, was admitted to the hospital. The patient required total care and was incontinent of bowel and bladder. Although alert and oriented to person and place, he was only able to answer simple yes-or-no questions.
During the shift change, a nursing assistant reported that the patient had not voided all shift. The patients bladder was not distended, and he did not report discomfort. The hospitalist was called and ordered an indwelling urinary catheter (IUC). Just before insertion of the catheter, the patient was incontinent of urine but the amount was not recorded. The RN reported this to the charge nurse, but the RN was told to proceed with the catheter insertion. The RN did so but did not obtain any urine. Because the patient had just voided, the RN assumed the patients bladder was empty. Two hours later, the patient began to report discomfort.
The RN was unable to irrigate the catheter and called the charge nurse, who found a blood clot in the tubing. The hospitalist was notied and ordered continuous bladder irrigation (CBI). The RN removed the catheter and inserted a three-way catheter for the CBI. An hour later, the patients pain increased and his bladder was distended. He was transferred to the emergency department, where a urologist performed a bladder scan and discovered the catheter was not in the bladder. A new three-way catheter was inserted after the second catheter was removed. The patient was transferred back to the ward, where he received two units of blood. The patient had the CBI for two days.
The patient experienced pain, a misplaced catheter, and three catheter insertions. He was put at risk for complications that included urinary tract infection, urosepsis, and bladder rupture. The misplaced catheter caused trauma to the urethra and blood loss. The patients wife led a complaint, and the hospital investigated in-house. The nursing staff members were unaware of the policy regarding bladder scanning before
catheter insertion or the policy that required documentation of both input/output and urinary volume.
DISCUSSION
This case illustrates errors that can occur with...