Safe Catheter Usage: Best Practices for Preventing Harm

A Foley catheter may be routine, but for over half of patients, it leads to complications. In fact, more than half of adults with an indwelling catheter reported at least one issue, with noninfectious problems like pain, bleeding, and trauma occurring five times more often than infections. These aren’t normal side effects; they’re preventable harms that delay recovery and drive up costs. Often, the cause is simple: a balloon inflated too soon, the wrong size, or a lapse in communication. But when teams treat each incident as a learning opportunity, safe catheter usage becomes a powerful tool for patient safety.

In this post, we’ll explore five evidence-based interventions for safe catheter usage and how incident reporting can transform frontline feedback into patient protection.

The Importance of Safe Catheter Usage

Each year, over 100 million patients undergo urinary catheterization procedures worldwide. However, one study found that up to 57% of Foley catheterizations lead to complications.

While Foley catheters are vital for various medical conditions, their misuse or improper management can result in serious consequences, including:

• Catheter-associated urinary tract infections (CAUTIs): According to the American Nurses Association, more than 560,000 patients develop CAUTIs each year in the United States.
• Urethral trauma or injuries: One study found that noninfectious complications from Foley catheters were five times as common as infectious complications. Noninfectious complications included bladder spasms, blood in the urine, and trauma to the skin.
• Increased healthcare costs: A single CAUTI is estimated to cost $13,793 on average but can be as high as $29,743, according to the Agency on Healthcare Research and Quality.

Ensuring safe catheter usage not only enhances patient outcomes but also benefits healthcare organizations in terms of expenses and quality.

Five Key Interventions to Enhance Catheter Safety

Drawing from the successful practices implemented at Texas Children’s Hospital, the Association of periOperative Registered Nurses (AORN) outlines five critical interventions to prevent catheter-related injuries:

1. Ensure Proper Catheter Placement

Proper training on catheter insertion techniques is crucial. Clinicians should:

• Confirm urine flow before inflating the catheter balloon.
• Utilize irrigation techniques if urine flow is not immediately observed.

These steps help verify correct placement and reduce the risk of injury.

2. Leverage Visual Cues

Visual aids serve as effective reminders for safe catheter practices. Successful examples implemented at the Texas Children’s Hospital include:

• Foley sizing cards placed in supply areas to assist in selecting the correct catheter size.
• Brightly colored stickers with messages like “Don’t Forget to HUB It” on catheter kits, reminding clinicians to fully insert the catheter to the hub before inflating the balloon, a crucial step in preventing urethral trauma.
• Digital bulletin boards displaying safe catheterization protocols in operating rooms.

3. Implement Regular Education Programs

Ongoing education ensures that staff remain informed about best practices for safe catheter usage. Annual training sessions should cover:

• Correct catheter selection and insertion techniques.
• Recognition and management of potential complications.

Regular competency assessments can help maintain high standards of care.

4. Update Catheterization Policies

Regularly revising institutional policies ensures they reflect current best practices. Key policy updates should include:

• Clarifying catheter sizing and placement techniques to ensure appropriate selection based on patient age and anatomy.
• Mandating full insertion of the catheter to the hub before balloon inflation to prevent urethral trauma, especially in pediatric patients.

5. Monitor and Share Injury Data

Collecting and analyzing data on catheter-related injuries enables healthcare teams to identify trends and areas for improvement. Sharing this data with staff fosters transparency and encourages collective responsibility for patient safety. Incident reporting can play a vital role in collecting, analyzing, and sharing this data.

The Role of Incident Reporting in Safe Catheter Usage

Incident reporting plays a critical role in identifying, understanding, and ultimately preventing catheter-related complications. Foley catheter usage presents risks ranging from infection to urethral trauma. These risks often go unaddressed until patterns emerge; those patterns only become visible through consistent reporting and analysis of incidents, near misses, and other safety events.

When catheter-related issues are reported—whether they involve improper placement, balloon inflation before insertion to the hub, or unanticipated patient reactions—organizations gain valuable data points. In other words, incident reporting turns individual mistakes or oversights into collective learning opportunities. These reports enable clinical and quality teams to:

• Spot recurring problems tied to specific procedures, shifts, departments, or locations. For example, if multiple reports flag improper sizing of Foley catheters, leadership can implement targeted retraining, update reference materials, or adjust supply availability to ensure the correct sizes are accessible where needed.
• Analyze root causes behind catheter-associated injuries, allowing for precise adjustments in clinical protocols or supply management. For example, if injuries are frequently linked to catheter insertions during surgical prep, the root cause might be traced to time pressure in the OR environment. A solution might involve adjusting pre-op workflows to allocate dedicated time for catheterization, ensuring the procedure isn’t rushed or deprioritized amid other tasks.
• Track outcomes over time to measure whether new interventions (such as visual reminders or policy changes) are effectively reducing harm. By comparing pre- and post-intervention data, teams can assess whether changes like “Don’t Forget to HUB It” stickers or revised catheterization checklists are actually reducing incident rates and improving compliance.
• Encourage knowledge sharing by circulating de-identified incident data across departments to raise awareness and reinforce safe practices. Sharing real cases (without patient or staff identifiers) in safety huddles or internal newsletters helps normalize reporting, fosters a culture of transparency, and prompts proactive discussion about preventing similar incidents elsewhere.

Ultimately, integrating catheter-related events into an organization’s broader patient safety reporting strategy ensures that interventions are data-driven, timely, and aligned with frontline needs. It creates a feedback loop where real-world incidents inform real-time improvements—helping to make safe catheter usage a sustainable standard.

Final Thoughts

Safe catheter usage is integral to delivering high-quality patient care. Implementing structured interventions like updating policies, ensuring proper placement, utilizing visual cues, providing regular education, and monitoring injury data, can significantly reduce catheter-related complications. Moreover, strengthening incident reporting systems will enable healthcare providers to identify risks promptly and implement corrective measures. Through these concerted efforts, healthcare organizations can improve patient safety and outcomes related to catheter use.

Achieve Safer Care Today

Every catheter-related event holds valuable insights… if you have the right tools to capture and act on them.

Performance Health Partners’ best-in-class incident management system transforms frontline reports into actionable data, helping you identify trends, prevent harm, and continuously improve care. From tracking complications to closing the loop on safety interventions, we make it easy to turn everyday risks into lasting improvements.

Ready to see it in action? Book a demo with our team for an up-close look at how our system supports safer, smarter care.