Through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified a risk of harm from catheterisation in patients with implanted artificial urinary sphincters.
An artificial urinary sphincter (AUS) is a surgically implanted device that is placed around the urethra or bladder neck, which is inflated to achieve continence or deflated to empty the bladder. The device is internally implanted and is not visible externally. If patients with an AUS require a catheter to be fitted, the cuff on the device must be deflated and the pump deactivated to avoid tissue damage, trauma, or infection.
The team’s review of the NRLS identified three incidents, over a three-year period, describing a lack of awareness the patient had an AUS device prior to a catheter being fitted. This information was shared with the British Association of Urological Surgeons and the British Association of Urological Nurses. To help prevent further patients being harmed the association updated its guidance documents for catheter care and patient information leaflets. The issue was also added to a consensus document providing guidance to staff for long term catheter care.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare.
A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.