Intermittent catherisation has the been the main stay of managing neurogenic bladder since the last half century. Despite its ease and applicability a large proportion of patients especially the tertaplegics find it  a difficult method to adopt  and most of these patient continue to be on an indwelling catheter which is changed every 3-4 weeks. 
It is not uncommon for patients with Spinal cord injury (SCI) to have urethral injury due to intra-urethral Foleys balloon inflation. This has been declared as a never event. Although several advances have been made in management of spinal cord injury patients during the last few decades, we continue to see this complication of Foley catheter balloon inflation in urethra in spinal cord injury patients.
Our aim was to prevent this iatrogenic complication which is a source of short term and long term morbidity in SCI patients by educating and training dedicated urology nurses and developing Cardinal principles for Foley catherisation in SCI patients.

All catherisations done on male SCI patients who were admitted in IPD over a three year period were studied for evidence of urethral injury. All catherisations done were recorded in the urinary catheter insertion chart in the case sheet. 
 A total of 5200 catherisations were done on 3100 SCI patients by Urology nurses. 
All catherisations were performed by Six  of our dedicated trained urology nurses who were taught the following  5 cardinal principles  of Foleys insertion in the SCI  patients.

1.	Use of adequate lubrication (instillation of 20 ml of lidocaine jelly with a waiting period of 5 minutes)
2.	Filling of bladder with 100 ml of saline through the existing (old) catheter in case of catheter change.
3.	Inserting catheter up to the hub and inflating the balloon (without resistance) only when there is free flow of urine/saline.
4.	Pulling the catheter back to feel the catch on bladder neck and then pushing the catheter back into the bladder the “YO-YO” sign. (If the catheter can easily be pushed back inside the bladder its definitely not in the urethra)
5.	Flushing the catheter with 50 ml of normal saline using a leur lock syringe
      (fits easily into the Foleys) , if it bypasses right out the urethra, or won’t inject,
      the catheter is probably not positioned correctly and ensuring that the volume of 
      fluid flushed into the bladder can easily be aspirated with the syringe.

Only three episodes (0.05%) of Intra-urethral balloon inflation were identified. Two were identified immediately by signs and symptoms of autonomic dysreflexia, Ultrasound confirmed the absence of balloon in the bladder and these patients underwent emergency flexible urethroscopy and catheter placement. One patient presented with urosepsis two weeks after the catherisation and required a suprapubic cystostomy. Ultrasound confirmation of intra-vesical balloon placement was required only in five catherisations when the urology nurse was not confident of the correct placement of catheter.

The rate of Intra-urethral balloon inflation was near zero(0.05%). We were able to reduce   the rate of this iatrogenic complication by training and educating our existing urology nurses without incurring any added extra cost.  The Urologist work burden due to traumatic catherisation was considerably reduced and urological resources and skills could be better utilized. Ultrasound confirmation was required only in 0.1% of cases and consequently ensued optimal utilisation of radiology services.

Intra-urethral balloon inflation is more common in SCI patients because of lack of sensations and altered anatomy and the magnitude of this iatrogenic complication is often underestimated. Apart from creating short term and long term morbidity they are a source of medico legal cases,  monetary loss and  lead to an increased burden on urological resources, and skills. By training and educating our urology nurses we were able to form a core of Catherisation nurses who performed all the Foley catherisations in the hospital using the five cardinal principles. By utilisation of these five simple steps(principles) we may be able to achieve a zero rate of intra-urethral Foley catheter balloon inflation in Spinal Cord Injured patients.