Urinary catheterisation can kill. It is one of the most common healthcare interventions but carries the risk of ‘significant danger’ to patients from infection (Pratt et al 2001). While essential for some patients, this invasive procedure is sometimes unjustified and even forgotten once in place (Saint et al 2005). Accountability for the safe management of urinary catheters by using evidence-based guidelines is emphasised. New ways of examining practice and planning for improvement (Department of Health 2005), and new technology (Tambyah 2004) will contribute to better outcomes for those patients for whom the procedure is essential.