The forgotten ureteric stent: what next?
Article first published online: 16 APR 2014
© 2013 The Authors. BJU International © 2013 BJU International
Volume 113, Issue 6, pages 850–851, June 2014
How to Cite
Withington, J., Wong, K., Bultitude, M. and O'Brien, T. (2014), The forgotten ureteric stent: what next?. BJU International, 113: 850–851. doi: 10.1111/bju.12357
- Issue published online: 6 JUN 2014
- Article first published online: 16 APR 2014
- Accepted manuscript online: 8 JUL 2013 05:52AM EST
Indispensable in a variety of elective and emergency scenarios, ureteric stents are inserted in large numbers by urologists, renal transplant surgeons and interventional radiologists. It is partly the scale of their use that makes it difficult to keep track of stents and when they are due for removal.
The forgotten ureteric stent is a ‘never event’, because it is entirely preventable and conveys the potential for serious harm. Forgotten stents tend to encrust and encrusted stents are difficult to remove, frequently entailing significant complications . Singh et al. , from a retrospective series of 19 forgotten ureteric stents, even reported one death as a direct consequence. Clearly, strategies for the prevention of this harm are essential.
Medico-legal accountability for the timely removal of a ureteric stent clearly resides with the surgeon responsible for its insertion, and failure to do so therefore leaves that surgeon liable to prosecution. Nadir et al.  reviewed details of all claims closed with an indemnity payment pertaining to urology, obtained from the NHS litigation authority. Forgotten ureteric stents accounted for the largest number of successful postoperative negligence claims: 23 claims in 14 years. In addition to individual responsibility, however, it could be argued that organizations have a legal responsibility to construct systems that prevent forgotten stents.
Sancaktutar et al.  investigated the financial burden caused by forgotten stents. Unsurprisingly, the occasional need for emergency admission and subsequent re-admission for complex endourological intervention, often spread across multiple sessions and entailing prolonged hospital admissions, exceed the cost of the relatively simple processes involved in routine stent removal. This financial imperative provides additional justification for the development of secure preventative strategies.
Existing systems for tracking stents are based on registries. Stent card-based versions, as described by Tang et al. , have been superseded by electronic registries, with built-in automated reminders.
The electronic approach has shown the potential to effect improvement, but there has been concern about the reliability of surgeons' data entry. Even after Lynch et al.  incorporated an elegant barcode system into their registry, it still failed to capture 13% of patients. Furthermore, recording the insertion of a stent in a registry does not ensure that stent is later removed. The system advanced by Lynch et al. incorporated an automated emailed reminder to prompt the responsible surgeon to arrange stent removal. A registry is only as good as its data entry, but a reminder equally relies on a response and that response, in practical terms, equates to a further administrative task.
Notwithstanding the accountability of the responsible surgeon, the process of ensuring that a patient attends for stent removal clearly requires two things: the patient must be invited to attend and they must then attend. A patient who remembers they have a stent and understands that it must be removed is unlikely to allow their stent to be forgotten; therefore, a system that reminds clinicians and patients about the presence of the stent and its need for removal is required.
Awareness and Education
Protective mechanisms for preventing medical error must be designed with the most vulnerable patients in mind and this requires an understanding of what makes a patient vulnerable.
Anecdotally, it seems that patients who themselves forget that they have a stent or that it should be removed are more likely to be lost to follow-up; therefore it is reasonable to assume that patients with short-term memory impairment are vulnerable, including those affected by psychiatric comorbidity, substance misuse or dementia.
Many patients experience significant stent-related symptoms, making it hard for them to forget that they have the stent and, perhaps, focusing their minds on its scheduled removal. While stent symptoms clearly cannot be relied upon as a protective mechanism, the converse logic applies: those patients who do not feel the presence of a stent are probably at increased risk of being forgotten by the system. For example, there is evidence that patients with stents for malignant occlusion experience fewer stent symptoms than others  (although such stents are also less likely to encrust).
For patients to translate stent symptoms to an imperative for stent removal requires them to identify the stent as the cause of those symptoms. This in turn requires education by clinicians. Similarly, the understanding that ureteric stents can cause harm if not removed in time can not be assumed of a patient, but must be made explicit. The amount of new information with which a patient undergoing endourological intervention is burdened during their admission is massive. Emphasis of the importance of stent removal is essential.
Reporting their series of 22 forgotten ureteric stents, Monga et al.  assert the importance of patient education. Interestingly, however, despite repeated counselling, 10% of patients they identified as having retained stents subsequently failed to attend for planned surgical removal and were lost to follow-up.
It can be difficult to know when to stop. Some units with logs of stents send letters by registered post when patients do not initially attend or respond. Should we visit patients' homes to remind them? Perhaps there is no way of guaranteeing this never event becomes just that. Nevertheless, what is needed is an optimum preventative system designed with that aim.
A system that engages with patients seems best but securing patients' understanding and awareness can be problematic. To prevent the misery of forgotten stents, counselling and education may need to be reinforced with a perpetual, visible reminder.
A New Approach
In our institution, we have proposed a patient wrist band, to remind patients, their relatives, carers and clinicians (in primary, secondary and tertiary settings) that a stent is in place and must be removed in time. A system is envisaged, involving wrist bands in stent packs, with barcodes on the wrist bands. Before leaving theatre (or the interventional suite), the wrist band would be placed, and then scanned, entering the patient into a registry that would then automatically book an appointment for stent removal. Building on the established and popular concept of the stent registry, human factors would be effectively removed from the booking process. Crucially, the patient would also be left with a visible reminder of the importance of timely stent removal, in case any other part of the process should fail.
Surgeons tend to be better communicators than administrators. Time saved on laborious, inefficient and erratic ‘admin.’ could be spent educating patients on the importance of timely stent removal. The wrist band would reinforce that message. Clearly, wrist bands would be worn with patients' consent and some patients, for example those with long-term stents for malignancy, might reasonably opt out.
Giving all patients a wrist band may seem disproportionate to urologists who believe they have never forgotten a ureteric stent, but the clinical, legal and financial imperatives have been outlined and the potential for improvement already demonstrated. It is our professional duty to finish the job and eradicate this preventable harm.
Conflict of Interest