Three cases of unrecognised, malpositioned saphenous vein percutaneous silastic catheters (PSCs) were identified among 21 saphenous vein PSCs placed over a 13 month period in one neonatal intensive care unit. All had been inserted in the left leg, and the inserting practitioner failed to identify malpositioning of the PSC tip on a frontal abdominal view obtained with contrast (fig 1A). Radiologists later identified the probable abnormal position based on the course of the PSC, and lateral views of the abdomen on the same day of insertion showed the superficial position of the catheter tip in the anterior abdominal wall (fig 1B).