QI: Unseen Perils of

Urinary Catheters
By:
Kristine Cavan
Jennifer Ceglowski
Lori Reiser
Amanda Temple

Background
John Smith
68 y/o male
History:
Hypothyroidism
HTN
Seizures
Cerebrovascular attack with hemiplegia
Dysphagia
Speech disorder
BPH with urinary retention
Monocular blindness

Received bolus feedings through a

gastrostomy tube and required
occasional suctioning of trach
Incontinent of bowel and bladder
Alert and oriented to person and place
Only able to answer simple yes-or-no questions

Background (Contd)
During evening shift change, a CNA reported the pt did not void all shift. His bladder was
not distended nor did he complain of discomfort. The MD ordered a urinary catheter. Just
before insertion, the pt voided but the amount wasnt recorded. The RN reported this to the
charge, who told her to proceed with the catheter insertion. No urine was produced. The
RN assumed the patient's bladder was empty. 2 hrs later, the pt complained of discomfort,
so the RN attempted catheter irrigation, but met resistance.

The charge was called, and found a blood clot in the tubing. The MD ordered continuous
bladder irrigation (CBI). The same RN removed the catheter and inserted a three-way
catheter, and the CBI began. An hour later, the patient's pain increased and his bladder was
distended. The CBI intake and output were in equal amounts. The patient was transferred to
ED. A urologist was called, who performed a bladder scan and discovered the catheter was
not in the bladder. The second catheter was removed and a new three-way catheter was
inserted by the ED RN. Blood returned from the new catheter. It was irrigated until clear,
and then CBI resumed. The pt was transferred back for observation and the next day he
received two units of blood. CBI was continued for 2 days.

The Problem
Patient suffered pain from a distended bladder, a misplaced
catheter, and 3 cath re-insertions.
He was put at risk for complications of UTI, urosepsis, and bladder
rupture.
The misplaced catheter caused urethral trauma and blood loss
requiring transfusion.
His wife filed a complaint with the facility, prompting an
investigation

Red Flags
The patient did not void all shift and primary RN did not intervene
The amount voided just before catheterization was not recorded
No bladder scan was done prior to catheterization
No urine was produced when patient was catheterized
Catheter irrigation met resistance
Blood clot observed in catheter tubing
Increased pain and bladder distention after 3-way cath insertion and
irrigation

Fishbone Diagram

Root Cause Analysis

1.Patient was was put at risk for complications that included urinary
tract infection, urosepsis, and bladder rupture. Misplaced catheter
caused urethral trauma and blood loss requiring transfusion and
prolonged hospitalization. Why?
2.Catheter had to be reinserted 3 different times. Why?
3.The initial urinary catheter was incorrectly placed and the RN did not
record urinary output. Why?
4.Bladder scan was not done to verify proper placement of catheter
and the RN did not record urinary output. Why?
5.The nursing staff were unaware of proper catheter insertion and the
policy about bladder scanning before cath insertion or the CBI policy
requiring documentation of I/O and urinary volume.

Problem:
PLAN:

DO:

Implement new education and training

program for nurses

In 2-2.5 months, the new program will be

put into daily practice by nursing staff

ACT:

STUDY:

New program will be incorporated into all

new hire training with annual refresher
training for all staff

Goal of zero improper urinary

catheterizations was not achieved within 3
months

PDSA: Aim
What are we trying to accomplish?
Decreasing number of improperly inserted catheters to zero within 3
months of education/training program implementation.

PDSA: Change in Practice

What changes can we make that will result in improvement?
Increase knowledge and competency of proper insertion of catheter
and adherence to policies requiring bladder scan to check for proper
placement and strict measurement of I/Os.
Establish consistency in urinary catheter insertion procedure on the
unit
Implement checklists and measurement tools with the goal of
reducing urinary tract infections, unintended use, and improper
insertion technique
Educate staff and all new hires on new unit protocol

PDSA: Plan
Tasks

Person
Responsible

When

Where

Develop curriculum to teach proper insertion and protocol

Nurse
Educator

Within 1
month

Education
department

Administration will develop checklists for proper UC

placement and require nurses to complete checklist before
every insertion

Administration
/Nurse
Manager/Nurs
es

Within 2
months

Administration
office/Floor

Train nursing staff on proper insertion and protocol. Post

protocol at each nurses station for quick reference

Nurse
Manager

Within 2
months

Staff meeting
room

Evaluate knowledge/skills

Nurse
manager

Ongoing
after
training

Staff meeting
room

Investigate reports for any incidents in which a urinary

catheter was placed incorrectly

Risk
Management
Team

Within 3
months

Risk
Management
Dept

PDSA: Plan
Prediction

Measures to determine
if prediction succeeds

Administration will develop checklists for proper UC

placement and within 2 months require nurses to
complete checklist before every insertion

Nurse Manager conducts chart review for any patient

with urinary catheter to verify that checklist was
completed

The nurse educator will develop curriculum to teach

proper UC insertion and protocol within 1 month

Curriculum will be 100% complete and cleared by

administration within 1 month

The nurse manager will be able to introduce and train

nurses on proper insertion to at least 90% of staff
within 2 months

Sign in sheet at training meeting

The nurse manager will evaluate knowledge and skills

Nurse manager will administer written test and skills

test to nurses after training. Passing score of 100% is
needed

Risk management team will identify zero improperly

placed urinary catheters

Risk Management team will document any wrong

catheter insertions

PDSA: DO
It should take 2-2.5 months, for the new program to be put into daily
practice by nursing staff
Nurse managers will continuously monitor and observe to make sure
program and checklists are completed properly

PDSA: Study
Prediction

Outcome

Administration will develop checklists for proper UC

placement and within 2 months require nurses to complete
checklist before every insertion

Administration developed checklists for proper UC

placement and within 2 months 95% of the times nurses
completed the checklist before insertion

The nurse educator will develop curriculum to teach proper

UC insertion and protocol within 1 month

100% of curriculum was developed and cleared by

Administration within 1 month

The nurse manager will be able to introduce and train

nurses on proper insertion to at least 90% of staff within 2
months

The nurse manager was able to introduce and train nurses

on proper insertion to 80% of staff within 2 months

The nurse manager will evaluate knowledge and skills

Nurse manager administered written test and skills test to

100% of nurses who completed training. Passing score of
100% was attained

Risk management team will identify zero improperly placed

urinary catheters

There were 3 reports of improperly placed urinary

catheters within 3 months of implementation

PDSA: Study
Problem

Solution

Ongoing staff trainings and assessments rely on

increased time and money for the hospital. Due to
this, nurse managers were unable to train 90% of
staff within 2 months

Keep training sessions short and focused. Introduce

use of online training to cut down on time required
by trainer and staff
Measure the efficacy of ongoing training by tracking
the rate of unsuccessful urinary catheter insertions.

Staff willingness to participate in ongoing trainings

Compliance with new evidence based procedure

Provide incentives and rewards for staff that adopt

new guidelines into their nursing practice

Nursing staff failed to complete checklist 5% of the

time

Managers remind staff of checklists and protocol

during staff huddles

Summary of Findings:
The new program has been successful at reducing the number of improper catheter insertions. Our aim of
decreasing the number of improper catheter insertions to zero was not quite reached. The 3 month time
frame may not have been enough time to develop a curriculum, train, evaluate and allow staff to become
accustomed to program and use of checklists.

PDSA: Act
What will you recommend as a result of your small test of change?
The new program will be incorporated into all new hire training with
annual refresher training for all staff so that staff will be informed in
proper technique

Stakeholder Analysis
Internal (unit) Stakeholders
Nurses
Charge Nurses
Nurse Managers
Administration
Nurse Educators

External Stakeholders
Patient and family
Community

Force Field Analysis

Prevent improper
placement of UCs
Preventing CAUTIs
Financial losses due to
hospital acquired
problems or
readmission
Repercussions,
including write ups for
noncompliance with
policy

Staff to be trained in proper

catheter insertion and
protocol. After training staff
knowledge and skills will be
evaluated using written test
and simulation. Staff will
properly insert catheter each
time. Checklists implemented
to insure compliance

Time

Limited resources

Cost to train, simulators,

equipment
Staff attitudes and
willingness to change

References
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