Dennis Willard v. State of IowaDennis Willard v. State of Iowa
Waterman, J., joins this dissent.
Matt J. Reilly of Eells & Tronvold Law Offices, PLC, Cedar Rapids, for appellee.
Erika Eckley, Des Moines, and T. Randall Wright of Baird Holm LLP, Omaha, Nebraska, for amicus curiae Iowa Hospital Association.
Paul Drey, Jeanine Freeman, аnd Allison M. Steuterman of Brick Gentry, P.C., West Des Moines, for amici curiae American Medical Association and Iowa Medical Society.
ZAGER, Justice.
In this interlocutory appeal, we are asked to determine whether a hospital’s Patient Safety Net materials are protected under the morbidity and mortality privilege, and whether this information is discoverable in this medical negligence action. Dennis Willard was seriously injured in a motor vehicle accident in Davenport, Iowa. After initial treatment in Davenport, Willard was transferred to the University of Iowa Hospitals and Clinics (UIHC) for further treatment. Because of the seriousness of his injuries, he was sedated and intubated. During his treatment at UIHC, Willard underwent a number of medical examinations and tests, one of which was an abdominal CT scan. Willard claims that while being transported to the CT scan and while undergoing the CT scan, UIHC was negligent in its handling of him. As a result, Willard claims he sustained an injury to his left shoulder and arm, in addition to his foot. After the CT scan, an employee of UIHC filed a PSN form about the incident. As part of his lawsuit for medical negligence against the State of Iowa,1 Willard requested discovery of the PSN and related documents. The State objected to the disclosure of the PSN and related documents, claiming the documents were privileged. Willard filed a motion to compel. After a hearing and briefing, the district court granted the motion to compel and ordered the State to produce the documents. The State applied for an interlocutory appeal and for a stay of the district court ruling, which we granted. For the reasons expressed below, we reverse the district court ruling and conclude the PSN and related documents are privileged under the morbidity and mortality statute and are not subject to discovery.
I. Background Facts and Proceedings.
Dennis Willard was involved in a head-on motor vehicle accident in the latе hours
Willard was transferred to the UIHC early in the morning on November 4. UIHC performed more imaging studies and x-rays, and the follow-up x-ray of Willard’s left shoulder again showed no break or dislocation. While at the UIHC, Willard’s condition deteriorated, which required that he be sedated and intubated. Because the doctors were concerned that Willard had sustainеd internal organ damage as a result of the accident, he underwent an abdominal CT scan on November 6. Willard remained sedated and intubated during the CT scan. In order to perform the CT scan, the imaging technologists were required to raise Willard’s arms above his head.
When Willard returned to his floor after the CT scan, staff noted that he exhibited a lack of motor response in his left arm and pain with range of motion. They requested an orthopedic team consult, and the orthopedic surgeon ordered more x-rays of Willard’s left shoulder. At this point, orthopedic surgeon Dr. Buckwalter diagnosed Willard with an anterior-inferior dislocation in the left shoulder, and he relocated it. Willard’s progress notes stated that orthopedics was consulted “regarding left anterior-inferior shoulder dislocation following a trip to CT for an abdominal exam.” The next day, Willard’s progress notes again stated that orthopedics had been consulted “after he sustained a left shoulder dislocation in an anterior inferior direction while obtaining a CT scan.”
Willard filed a petition at law and jury demand on November 24, 2014, pursuant to the
During the course of discovery, Willard submitted the following interrogatories:
INTERROGATORY No. 6: State whether you, your agents or attorneys have obtained any statement, either oral or written, from any person having knowledge of facts relating to the subject matter of this action, and if so, please state:
(a) the name and address of each person giving such statement;
(b) whether each such statement is written or recorded and signed or unsigned;
(c) the date, time, and place each such statement was taken;
(d) the name and present address of the person taking each such statement;
(e) the name and address of each person having custody and control of such statement;
(f) the substance of each such statement.
INTERROGATORY No. 16: Was any document withheld under any alleged privilege? If the answer was yes, identify each document for which a privilege is claimed, together with the following information: date, sender, recipients, recipients of copies, subject matter of the document, and the basis upon which said privilege is claimed.
Willard also made an initial request for documents seeking copies of any reports or memoranda relating to him, the incident referenced in his petition, or the injuries or damages included in his petition. In a supplemental request for documents, Willard requested “[a]ny PSN, unusual incident report or other incident report prepared by any agent or employee of Defendant in Novеmber 2011 that relates to or refers to Plaintiff.”
Willard filed the supplemental request for documents after deposing UIHC senior imaging technologist Cyndie Beaumont, who had assisted with Willard’s CT scan. During her deposition, Beaumont stated that she did not recall the CT scan itself, but does remember Willard because she learned that an incident report had been filed about the scan the next day. The incident report that was filed was a Patient Safety Net (PSN) form.
A PSN is an electronic form that allows UIHC employees to enter information about events that raise a safety concern for patients. The UIHC encourages stаff to enter a PSN for any safety concern, and thousands of PSNs are submitted every year. UIHC employees are informed that PSNs are confidential and protected. A submitted PSN may be used for a number of purposes, including but not limited to morbidity and mortality studies, a source for UIHC staff to review events, a source to determine trends, information to identify topics for research or conference presentations, and literary reviews.
Once a PSN is entered, it is submitted to an electronic database and reviewed by the UIHC quality department. This initial review is conducted daily, and the department determines where tо route each submitted PSN. The department may submit the PSN for review to a quality officer or the safety oversight team. The PSN may also be routed to the patient safety issues group of a specific department, such as anesthesiology.
The safety oversight team is a multidisciplinary group that reviews PSNs to identify trends and revises hospital policy based on those trends. A PSN is submitted for review to the safety oversight team if it is a “serious adverse event” or a “sentinel event.” A serious adverse event is an event that requires special intervention because the potential for serious injury is high. A sentinel event is a serious аdverse event that involved death or serious physical or psychological injury, or a serious adverse event that involved a high risk of death or serious physical or psychological injury. Once a PSN based on a serious adverse event or a sentinel event is submitted to the safety oversight team, the team determines whether a Root Cause Analysis (RCA) is required.
If an RCA is required, a group of content experts studies the underlying event and makes conclusions about the event and the contributing causes. The group then provides recommendations for reducing the risk of the same safety issue occurring in the future. Finally, the group prepares an action plan based on the recommendations and implements it.
The PSN system does not track how PSNs are used, so it is unknown whether Willard’s specific PSN was used for morbidity and mortality studies, research, an RCA, or quality improvement.
On June 9, the district court granted Willard’s motion to compel. The district court found that the State failed to meet its burden to establish the PSN was subject to the morbidity and mortality privilege contained in
On June 13, the State filed an application for interlocutory appeal and motion for stay of the district court ruling to produce the PSN and related documents, which we initially denied. On June 17, the State filed a motion for review of the denial. We stayed enforcement of the district court ruling pending our ruling on the motion for review. On June 24, we granted the application for interlocutory appeal and stayed further proceedings below.
II. Standard of Review.
We review a district court’s discovery decisions for an abuse of discretion. Jones v. Univ. of Iowa, 836 N.W.2d 127, 139 (Iowa 2013). An abuse of discretion exists when the district court’s ruling “rests upon clearly untenable or unreasonable grounds.” Id. (quoting Lawson v. Kurtzhals, 792 N.W.2d 251, 258 (Iowa 2010)). “A ground or reason is untenable ... when it is based on an erroneous application of the law.” Sioux Pharm., Inc. v. Eagle Labs., Inc., 865 N.W.2d 528, 535 (Iowa 2015) (quoting Office of Citizens’ Aide/Ombudsman v. Edwards, 825 N.W.2d 8, 14 (Iowa 2012)). “To the extent we ... engage in statutory interpretation, our review is for correction of errors at law.” DuTrac Cmty. Credit Union v. Hefel, 893 N.W.2d 282, 288-89, 2017 WL 461211, at *4 (Iowa 2017).
III. Analysis.
On appeal, the State argues that the morbidity and mortality confidentiality privilege applies to the PSNs at issue here pursuant to
A. Background.
In 2000, the Institute of Medicine (IOM) published a report entitled To Err Is Human: Building a Safer Health System, which analyzed common medical errors and how to prevent them. Inst. of Med., To Err Is Human: Building a Safer Health System (Linda T. Kohn, Janet M. Corrigan, & Molla S. Donaldson eds., 2000) [hereinafter To Err Is Human]; see also Tibbs v. Bunnell, 448 S.W.3d 796, 800 (Ky. 2014). The report estimated between 44,000 and 98,0005 people die annually in hospitals as a result of preventable medical errors. To Err Is Human, at 26. The majority of these preventable errors “were not the result of personal recklessness but rather resulted from faulty systems, processes, and conditions.” Lee Med., Inc. v. Beecher, 312 S.W.3d 515, 534 (Tenn. 2010). The report recommended that hospitals adopt a four-tiered system to make the health system safer for patients. To Err Is Human, at 6. The identified four tiers are (1) enhancing knowledge of patient safety, (2) identifying medical errors through both mandatory and voluntary reporting systems, (3) raising performance standards and expectations for improvement, and (4) adopting safety systems to ensure patient safety рractices. Id.
Following the publication of the report, Congress enacted the Patient Safety and Quality Improvement Act of 2005 (PSQIA), Pub. L. No. 109-41, 119 Stat. 424 (codified at
The Iowa Legislature originally enacted morbidity and mortality study statutes in 1963 and amended the statutes in 2006,
135.40. Collection and distribution of information.
Any person, hospital, sanatorium, nursing or rest home, or other organization may provide information, interviews, reports, statements, memoranda, or other data relating to the condition and treatment of any person to the department, the Iowa medical society or any of its allied medical societies, the Iowa osteopathic medical association, any in-hospital staff committee, or the Iowa healthcare collaborative, to be used in the course of any study for the purpose of reducing morbidity or mortality, and no liability of any kind or character for damages or other relief shall arise or be enforced against any person or organization that has acted reasonably and in good faith, by reason of having provided such information or materiаl, or by reason of having released or published the findings and conclusions of such groups to advance medical research and medical education, or by reason of having released or published generally a summary of such studies.
....
135.41. Publication.
The department, the Iowa medical society or any of its allied medical societies, the Iowa osteopathic medical association, any in-hospital staff committee, or the Iowa healthcare collaborative shall use or publish said material only for the purpose of advancing medical research or medical education in the interest of reducing morbidity or mortality, except that a summary of such studies may be released by any such group for general publication. In all events the identity of any person whose condition or treatment has been studied shall be confidential and shall not be revealed under any circumstances. A violation of this section shall constitute a simple misdemeanor.
135.42. Unlawful use.
All information, interviews, reports, statements, memoranda, or other data furnished in accordance with this division and any findings or conclusions resulting from such studies shall not be used or offered or received in evidence in any legal proсeedings of any kind or character, but nothing contained herein shall be construed as affecting the admissibility as evidence of the primary medical or hospital records pertaining to the patient or of any other writing, record or reproduction thereof not contemplated by this division.
Id.
B. Iowa Code Section 135.40.
The first issue we must address is whether the PSN qualifies as a morbidity and mortality study under
When we interpret a statute, we apply well-settled principles of statutory interpretation:
The purpose of statutory interpretation is to determine the legislature’s intent.
We give words their ordinary and common meaning by considering the context within which they are used, absent a statutory definition or an established meaning in the law. We also consider the legislative history of a statute, including prior enactments, when ascertaining legislative intent. When we interpret a statute, we assess the statute in its entirety, not just isolated words or phrases. We may not extend, enlarge, or otherwise change the meaning of a statute under the guise of construction.
DuTrac, 893 N.W.2d at 294 (quoting Howse, 875 N.W.2d at 691). We construe a statute “liberally with a view to promoting its objects and assisting the parties in obtaining justice.” Star Equip., Ltd. v. State, 843 N.W.2d 446, 455 (Iowa 2014) (quoting Lennox Indus., Inc. v. City of Davenport, 320 N.W.2d 575, 578 (Iowa 1982)).
Morbidity and mortality are not defined by statute. Morbidity can be defined as “a diseased state or symptom,” “the incidence of disease : the rate of sickness,” or as a collection of statistics on an illness. Morbidity, Webster’s Third New International Dictionary (unabr. ed. 2002). Mortality can have a number of meanings, including “the death of large numbers : a heavy loss of life (as by war or disease),” either the whole sum of deaths or a proportion of deaths per population, or a “rate of loss or failure in a field of human endeavor.” Mortality, Webster’s Third New International Dictionary. Taken together with their common meanings, a morbidity and mortality study can be interpreted broadly to mean a collection of statistics or a study regarding the rates of illnesses, diseases, or death among a patient population.
Further, the morbidity and mortality statute hаs an expansive scope, which is demonstrated throughout the text of
Hospitals are required to have ongoing, hospital-wide quality improvement programs in place that allow them to assess clinical patient care and nonclinical and patient-related services within the hospital, and to develop remedial action if necessary.
A PSN clearly falls within the legislative intent of “any study for the purpose of reducing morbidity or mortality.”
C. Iowa Code Section 135.41.
The second issue we must address is whether
The statute does not make a distinction between a third party request for information and Willard’s request for information, and we decline to read such a distinction into the statute. Furthermore, Willard is not requesting a summary of any morbidity and mortality study, but the PSNs themselves. We find that the release of the PSN is not required by
D. Iowa Code Section 135.42.
The final question we must answer is whether the PSN is subject to discovery under
The district court has wide discretion in rulings on discovery. Carolan, 553 N.W.2d at 886. We construe discovery rules liberally in order to assist in the disclosure of all relevant and material information. Id. However,
Under the doctrine of last preceding antecedent, a qualifying word or phrase only refers to the immediately preceding antecedent unless the language of the statute clearly demonstrates a contrary legislative intent. Iowa Comprehensive Petroleum Underground Storage Tank Fund Bd. v. Shell Oil Co., 606 N.W.2d 376, 380 (Iowa 2000). “[E]vidence that a qualifying phrase is supposed to apply to all antecedents instead of only to the immediately preceding one may be found in the fact that it is separated from the antecedents by a comma.” State v. Gen. Elec. Credit Corp., 448 N.W.2d 335, 345 (Iowa 1989) (quoting 2A Sutherland, Statutes and Statutory Construction § 47.33 (4th ed. 1984)).
Under this doctrine, the phrase “in evidence” only applies to the word “received” because it is the only word immediately preceding the phrase “in evidence” and there are no commas separating the words “used,” “offered,” and “received” in the statute.
Additionally, when a statute is ambiguous, we may consider the “consequences of a particular construction” in determining the legislature’s intent.
The overall statutory scheme regarding morbidity and mortality information and studies is broad. As discussed earlier,
We likewise find that the legislature intended
We considered similar public policy considerations in Carolan, 553 N.W.2d at 886. Although Carolan dealt with the confidentiality of peer review records, see id., we nevertheless find the rationale similarly persuasive in the context of PSNs and relаted documents. We noted that confidentiality was imperative because
[p]eer review privileges encourage an effective review of medical care. If such records were privileged only when directed at a specific licensee, hospitals would have difficulty conducting reviews of their health care departments. Without the broad protections, physicians would be very reluctant to participate, knowing the information could easily be revealed in a court of law.
The same is true for PSNs and the related documents. There is a strong public policy argument fоr interpreting
IV. Conclusion.
For the above reasons, wе reverse the decision of the district court. We find that the PSN and related documents are the type of information covered by the morbidity and mortality statute and are therefore privileged under
REVERSED AND REMANDED.