DAL 17-08 - Identification, Labeling and Storage of Human Remains

April 26, 2017

DHDTC DAL 17-08: Identification, Labeling and Storage of Human Remains

Dear Chief Executive Officer:

The purpose of this letter is to raise your awareness of the potential for error in the identification, labeling and storage of human remains. Human remains mix-ups occur infrequently, but are highly emotional for all involved when they occur, often triggering litigation against the hospital and/or funeral director that was engaged to pick up the remains. The New York State Department of Health (Department) has become aware of multiple human remains mix-ups through complaints from affected family members and through media reports. In order to prevent such occurrences, the Department strongly encourages hospitals to perform a system review of their policies and procedures that address the process for identifying and labeling human remains, as well as, the process by which funeral directors pick up the human remains for final disposition.

While there is a dearth of best practice information on this subject, it is clear that strong policies guiding staff actions are needed. The following represent areas for hospitals to consider when examining systems related to human remains:

  • Identify all areas of the hospital where policies regarding human remains must be in place. Primarily, hospitals should examine the identification and labeling processes that occur when patients die on an inpatient floor or in other patient care area. For example, hospitals should also review and examine the policies that exist for remains that are sent to pathology for inspection before final disposition.
  • Address the hospital's process for labeling and tracking of fetal remains. Fetal remains may be especially vulnerable to errors in handling. Labeling and storage are critically important for these remains because they may be handled as regulated medical waste or be released to a funeral director for disposition, depending upon weeks of gestation and the family's wishes. For remains that are handled as regulated medical waste, consider storage in a separate location from those remains that will be released to a funeral director.
  • Assure that labeling of human remains involves verification of the patient's identity. Patients with similar names and spellings have been involved in both near-miss and actual remains mix-ups. Some hospitals leave the patient's wrist identification band in place after death so that it can be easily matched with any labels placed on the shroud or body bag. This practice may useful for both hospital staff and funeral directors to identify and to verify human remains for transfer or removal.
  • Include tracking of near-miss and actual events involving human remains in your hospital's quality assurance efforts. Active monitoring of near-miss and actual events are critical to performance improvement in this area.
  • Discuss your hospital's process for picking up of human remains with the funeral directors in your region. Together, opportunities for process improvements can be identified and addressed.
  • Develop a log to register human remains that are delivered to and checked out of your hospital's morgue. Hospitals may wish to consider concurrent sign-off for hospital staff and funeral directors when human remains are transferred to the custody of the funeral director. Additionally, staff should be assigned to review and reconcile the entries in the log on a routine basis to assure that all remains have been appropriately handled.

lease take this opportunity to review your current policies and procedures regarding the ways that human remains are identified, labeled, and removed for final disposition. Your attention to this matter may prevent an unfortunate mix-up from occurring at your hospital.

Should you have any questions, please contact the Division of Hospitals and Diagnostic & Treatment Centers at 518-402-1004.

Sincerely,

Ruth Leslie
Director
Division of Hospitals and Diagnostic & Treatment Centers