House Staff Manual - Winthrop University Hospital

should be referred to Risk Management and Insurance Services (ext. 2206) if the next-of-kin or health careagent refuses the recommended surgery or treatment.CONSENT FOR RESEARCH PARTICIPATIONPatients or any subjects who are invited to participate in a research protocol at Winthrop must sign aconsent form officially approved by Winthrop’s Institutional Review Board prior to being enrolled in astudy.72. INSTITUTIONAL REVIEW BOARDThe Institutional Review Board is a federally-mandated committee which reviews all proposed and activeHospital research programs involving human subjects. This shall include all investigational drugs andexperimental new devices, experimental non-therapeutic studies as well as those behavioral orpsychological studies which may incur significant risk. All projects, both externally funded as well asinvestigator-initiated must be submitted for IRB review and approval prior to inception.The primary responsibility of the IRB is to inquire into and fully evaluate the moral and ethicalconsiderations of proposed projects in order to guard the human rights of the involved subjects. In thisregard, among the responsibilities of the IRB are:• to insure that adequate and proper informed consent is obtained and is freely given by the researchsubjects.• to insure that the possible risk to the subjects is balanced by the potential benefits to the subjects and/orto society.• to insure that periodic reporting of the progress of research studies to the IRB is established andmaintained.Members of the House Staff may call the IRB administrative office at ext. 2552 for guidance, materials andassistance with the submission of a new project.73. ORGAN AND TISSUE PROCUREMENTBy New York State Law, when a patient dies in the hospital the New York Organ Donor Network must benotified immediately. Notification is done by Nursing, but House Staff play an important initial role incases where patients are on ventilators in the ICU. If the patient has been declared brain dead, or is beingevaluated under Brain Death criteria, the Donor Network must be notified immediately. House Staffshould be aware of the need for timeliness and of communicating the patient’s status to nursing personnel.The Uniform Anatomical Gift Law includes all patients, ages newborn to 86, excluding those with knownHIV. A Donor Network representative will call back to screen the patient for potential donation, based onchart information. If the patient is deemed a suitable candidate, the representative makes the request of thefamily, and coordinates with the appropriate retrieval organizations.74. PATIENT IDENTIFICATION BRACELETSAccurate and consistent patient identification is essential to the delivery of patient care services. Patientidentification is the responsibility of every member of the hospital staff who interacts with patients orintervenes in their care.Hospital policy requires that prior to any encounter or procedure, hospital personnel (including HouseStaff) verify the identification bracelet by asking the patient to state his/her name (if able) and then check tobe sure that the stated name coincides with the name on the bracelet. If it coincides, House Staff shouldRev. 1/08