Improper Catheter Placement Causes Permanent Injuries

This case involves a patient with severe injuries from an accident at work in the state of Colorado. During the patient’s admission a urinary catheter was placed. Shortly thereafter, the patient complained of pain for several hours. The patient’s penis was found to be swollen on examination. A urologist was then contacted, who said that a false passage was created by the catherization. The urologist removed the catheter and placed another in the correct position. The patient was discharged from the ICU and brought to a rehab facility. He was at the rehab facility for 5-6 days where he continued to complain about pain. The swelling of the penis also persisted. The patient was returned to the hospital where he was diagnosed with gangrene on his penis.

Question(s) For Expert Witness

1. Do you perform catheterizations? If so, how often?

2. What precautions are taken to prevent the problem seen in this case?

3. Are you able to review the medical notes and comment on the adequacy of the post-catheterization orders?

Expert Witness Response E-009304

I perform 8-12 indwelling Foley catheter placements weekly. The proper technique for indwelling catheter placement involves insertion of the catheter to its hub and watching for return of urine. While a false passage may not be avoidable, recognition of improper catheter positioning should be suspected. I can review the notes and comment on the adequacy of the post catheterization orders.