SHM Converge Scientific Abstract ePoster Gallery-Retrospective Chart Review of Patients With Iatrogenic Urinary Catheterization: A Descriptive Study

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This retrospective chart review examined hospitalized adults at Michigan Medicine who received Urology consultation for difficult or traumatic urinary catheterization between January 1, 2022, and December 31, 2024. From a resident-maintained consultation database, the researchers randomly selected 100 cases for detailed review, with equal representation of males and females. They focused on catheterization details, risk factors, and documentation quality, and found excellent reliability in chart abstraction.<br /><br />The study found that non-infectious catheter complications often occurred in inpatient and perioperative settings, frequently after multiple insertion attempts by nursing staff and usually involving Foley catheters. Trauma commonly occurred soon after insertion, emphasizing the importance of correct technique and early recognition of injury. Urology reinserted catheters with different sizes in most cases, suggesting individualized decisions based on anatomy and clinical circumstances.<br /><br />Risk factors varied by gender. In males, difficult placement was commonly associated with enlarged prostate-related issues, multiple attempts, and urinary retention. In females, common contributors included multiple attempts, urinary retention, bladder anatomic issues, and genitourinary infection. In transgender women, altered genital anatomy, bladder fistula, and prior lower urologic surgery were noted. Positioning difficulty also differed: males were affected by limited cooperation and GU tumors; females by limited leg mobility, genital edema, cooperation, and GU tumors; no specific positioning factors were identified in transgender patients.<br /><br />The authors concluded that electronic health records can reliably capture key patient characteristics in these cases, but documentation gaps remain, especially regarding catheter size and mention of trauma in discharge summaries. Nearly half of discharge summaries failed to note catheter trauma. The study highlights the need for better education, standardized catheterization protocols, and improved documentation, particularly for patients at higher risk of difficult placement or catheter-related trauma.

Asset Subtitle

Esther C. Lee

Meta Tag

Author List Catherine Sulich, Esther C. Lee, Jennifer Meddings, Jessica Ameling

Category Research

Concept Catheterization

Concept Non-infectious Complication

Concept Difficult Placement

Concept Iatrogenic Trauma

Concept Retrospective Chart Review

Distinguished Non-Finalist

Presenter Organization University of Michigan

Presenting Author Esther C. Lee

Track Patient Safety

Keywords

urinary catheterization

urology consultation

catheter trauma

difficult catheter placement

electronic health records

hospitalized adults

Foley catheter

documentation quality

risk factors

retrospective chart review

Catheterization

Non-infectious Complication

Difficult Placement

Iatrogenic Trauma

Retrospective Chart Review