NPSA are issuing this Rapid Response Report to stakeholders in England and Wales and request IMMEDIATE ACTION by all acute, mental health and primary care organisations in the NHS and independent sector. The deadline for ACTION COMPLETE is no later than 1 September 2009.

All other recipients of this Rapid Response Report are being sent for information purposes.

Background:
Adult urinary catheters are manufactured in two lengths: female length (20-26cm), and standard length (40-45cm). The use of standard length catheters in females poses no safety issues, as the shorter female length is designed for dignity issues when wearing skirts rather than trousers. However, if a female length catheter is accidentally used for a male, the 'balloon' inflated with sterile water to retain the catheter will be within the urethra, rather than the bladder, and can then cause severe trauma.

* Make sure you select the correct size catheter

* Female-only catheters can cause severe trauma and haemorrhage if used in males.

* Standard length catheters (40-45cm) can be used for males or females. Shorter catheters (20-26cm) are for females.

Actions:
Chief Executives should nominate an appropriate person to ensure that:

1. This Rapid Response Report is immediately distributed to all staff who insert urinary catheters in teenage or adult male patients, and to community pharmacists who dispense urinary catheters.

2. Current supply systems for female length catheters are reviewed, with the aim of limiting access where appropriate (for example, an acute hospital supplying female length catheters only via a specialist ward or specialist nurses rather than routinely stocking them on every ward).

3. Where female length catheters are stocked in any setting where teenage or adult males are also treated, a warning notice is displayed close to the stock of female length catheters (warning posters can be downloaded from http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/catheters/ ).

4. Where female length catheters are stocked in any setting where teenage or adult males are also treated, wherever possible additional clear warning labels are attached to each catheter before these are distributed to individual clinical areas or community staff bases (see http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/ for important steps to ensure labelling is carried out safely, and labels for downloading)

5. The content of local competency based training for urinary catheter insertion is reviewed to ensure it includes selection of catheters of the correct length.

Information to support implementation:
More information and resources, downloadable labels and warning posters are available at http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/catheters/ or contact rrr@npsa.nhs.uk or telephone 020 7927 9890.