In May, a packet of information outlining physician obligation on transfusion is being sent to members of the medical staff, announced Lawrence M. Shuer, chief of staff. Both the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and state law (the Gann Act) require all physicians (medical and surgical services) to review the risk benefits of and alternatives to expected blood transfusions.

Shuer said that SHS is putting into place a policy that allows physicians to sign a form attesting that they have provided appropriate education to patients. A copy of that form will be included in the packet that will be mailed to staff members in May.

"It is crucial that physicians document the review of risk benefits and alternatives for blood transfusions in the medical record at least once during a treatment course for both inpatients and outpatients, " Shuer explained.

Shuer also noted that JCAHO requires SHS to monitor compliance with the medical staff bylaws policy on autopsies, which states: "In the event of a patient death in the hosptial, the attending/service is expected to attempt to obtain permission to perform an autopsy."

To monitor compliance, the blue-colored "draft death certificate" has a few fields added to ascertain whether the family was approached about autopsy and whether permission was granted or denied.

"When filling out the draft death certificate, all attendings and house staff should complete this area on the form so that we can monitor our compliance and ensure a clean bill of health with our monitoring agencies," Shuer said.