475 Forgotten Antegrade Ureteric Stent: What Can We Do?

Abstract

Abstract Introduction In the UK, forgotten ureteric stents are considered a ‘never event’ and hence can be a source of significant litigation. Forgotten ureteric stent was the most frequent postoperativerelated claim over 14 years in 2011. Aim To assess the possible risk factors for missing an antegrade (AG) stent in a patient. Method Retrospective data collection from Interventional radiology (IR) department: 1. Date of AG stent insertion 2. Date of request for the next step (definitive treatment either removal or exchange) To assess: • Time lag = Number of days between AG stent insertion and requesting the definitive procedure • Any other possible risk factors for ‘forgotten stent’ Audit Results Audit (01 Jan – 15 Dec 2019): • Total number of cases (N) = 45. • Time lag: Range 1 up to 73 days (Mean: 13.1 days). Action plan 1-requests for AG stent insertion must come only via urology team 2-on AG stent request, provisional draft is already drafted 3-AG stent request generates auto,atci request for the next uro-radiology meeting as a safety net 4-in IR, documentin patient notes and flag to uro-radiology meeting 5-discharge summary to include stent management time frame. Re-audit Results (01 Jan – 30 Jun 2020): • Total number of cases (N) = 30. • Time lag: Range – 1 up to 11 days (Mean 3.5 days). Conclusions Safe practice of AG stent insertion requires coordination between urology and radiology departments to action a plan for stent removal /exchange can safety net such patients and avoid the hazard of a ‘forgotten stent’.