Amended June 22, 2017 Dennis Willard v. State of Iowa ( 2017 )


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  •                 IN THE SUPREME COURT OF IOWA
    No. 16–1009
    Filed April 7, 2017
    Amended June 22, 2017
    DENNIS WILLARD,
    Appellee,
    vs.
    STATE OF IOWA,
    Appellant.
    Appeal from the Iowa District Court for Johnson County,
    Mitchell E. Turner, Judge.
    The State appeals from a district court ruling granting plaintiff’s
    motion to compel discovery. REVERSED AND REMANDED.
    Thomas J. Miller, Attorney General, Jeffrey S. Thompson, Solicitor
    General, and Forrest Guddall (until withdrawal) and Anne Updegraff,
    Assistant Attorneys General, for appellant.
    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.
    2
    Paul Drey, Jeanine Freeman, and Allison M. Steuterman of Brick
    Gentry, P.C., West Des Moines, for amici curiae American Medical
    Association and Iowa Medical Society.
    3
    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.
    1UIHC   is owned, operated, and controlled by the State of Iowa.
    4
    I. Background Facts and Proceedings.
    Dennis Willard was involved in a head-on motor vehicle accident in
    the late hours of November 3, 2011.         Willard sustained significant
    injuries from the collision and was initially treated at the Genesis
    Medical Center East in Davenport, Iowa.         While at Genesis, Willard
    underwent imaging studies and x-rays.         One of the x-rays covered
    Willard’s left shoulder and showed no break or dislocation.
    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 sustained 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.”
    5
    Willard filed a petition at law and jury demand on November 24,
    2014, pursuant to the Iowa State Tort Claims Act. 2 The underlying basis
    for Willard’s claim is that he was negligently handled while sedated,
    causing him to sustain injuries to his left shoulder, arm, and foot. He
    argues the State owed him a duty to exercise reasonable care in
    transporting him while sedated and the employees of the hospital
    breached that duty. He asserts that the x-rays from Genesis and the x-
    rays taken at UIHC on November 4 do not show a left shoulder
    dislocation.     However, the x-ray taken after the abdominal CT scan
    shows a left shoulder dislocation, which indicates his shoulder was
    dislocated during the CT scan procedure.
    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
    2Iowa   Code chapter 669 (2015).
    6
    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 November 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 staff 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
    7
    conducted daily, and the department determines where to 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 adverse 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.
    8
    On March 14, 2016, Willard filed a motion to compel the PSN and
    related pages. 3      The State acknowledged that it had in its possession
    twenty-four pages of materials that included the PSN and related
    documents, but it objected to the disclosure of the material. The State
    resisted Willard’s motion, arguing that the documents were privileged
    under the morbidity and mortality privilege contained in Iowa Code
    sections 135.40 through 135.42. See Iowa Code §§ 135.40–.42 (2015).
    Further, the State argued the documents were not discoverable under
    section 135.42.        The district court held an evidentiary hearing and
    ordered the State to produce the PSN and related documents for an in
    camera review.
    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 section 135.40. The district court found that the morbidity
    and mortality statute was created for situations where data is collected
    for a study, but that the State did not meet its burden to establish that
    the PSN was created or used for the course of any study for the purpose
    of reducing morbidity or mortality.          The district court also found that
    section 135.41 did not apply because the case did not involve a third
    party. The district court found that section 135.42 dealt with the issue
    of admissibility, but not discoverability, of the requested documents. The
    district court found that because discovery rules are to be liberally
    construed and the information contained in the documents could
    3Originally, the State acknowledged it had possession of a four-page PSN and
    associated eight pages. The State later discovered a second four-page PSN and related
    eight pages. The State’s discovery response was supplemented to acknowledge that it
    had in its possession the twenty-four pages but objected to their disclosure.
    9
    reasonably lead to admissible evidence, the PSN was subject to discovery.
    The district court also found that the attorney–client and work-product
    privileges did not apply. The district court ordered the State to produce
    the PSN and related documents to the plaintiff within twenty days. It
    also ordered Willard not to disclose the documents to anyone except his
    expert witnesses.     Any other proposed disclosures would need the
    approval of the district court.
    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, ___ N.W.2d ___, ___ (Iowa 2017).
    10
    III. Analysis.
    On appeal, the State argues that the morbidity and mortality
    confidentiality privilege applies to the PSNs at issue here pursuant to
    Iowa Code sections 135.40–.42. 4 The State further argues that the PSN
    and related documents are not subject to discovery based on the specific
    language of Iowa Code section 135.42.             When a privilege is statutory,
    “the terms of the statute define the reach of the privilege.” Carolan v.
    Hill, 
    553 N.W.2d 882
    , 886 (Iowa 1996). In order to determine whether
    the PSNs are entitled to the privilege, statutory interpretation must be
    employed. “The purpose of statutory interpretation is to determine the
    legislature’s intent.” State v. Howse, 
    875 N.W.2d 684
    , 691 (Iowa 2016)
    (quoting Schaefer v. Putnam, 
    841 N.W.2d 68
    , 75 (Iowa 2013)).
    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
    4Neither   Willard nor the district court dispute that the statute creates a
    privilege.
    5Atthe time the report was published, this would have made preventable
    hospital deaths one of the leading causes of death in the United States, with even the
    lower number surpassing deaths due to motor vehicle accidents, breast cancer, or
    AIDS. To Err Is Human, at 26–27.
    
    11 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 practices. 
    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 42 U.S.C. 299b-21 to 299b-26 (2012)).
    “The Patient Safety Act ‘announces a more general approval of the
    medical peer review process and more sweeping evidentiary protections
    for materials used therein.’ ” Dep’t of Fin. & Prof’l Regulation v. Walgreen
    Co., 
    970 N.E.2d 552
    , 557 (Ill. App. Ct. 2012) (quoting KD ex rel.
    Dieffenbach v. United States, 
    715 F. Supp. 2d 587
    , 595 (D. Del. 2010)).
    The purpose of the PSQIA was “to encourage the reporting and analysis
    of medical errors and health care systems by providing peer review
    protection of information reported to patient safety organizations for the
    purposes of quality improvement and patient safety.” 
    Tibbs, 448 S.W.3d at 801
    (quoting H.R. Rep. No. 109–197 (2005)). The protections included
    in the Act were intended to apply to documents or communications that
    constitute “patient safety work product.” 
    Id. The Iowa
    Legislature originally enacted morbidity and mortality
    study statutes in 1963 and amended the statutes in 2006, after the
    publication of the IOM report and the enactment of the PSQIA. Compare
    Iowa Code §§ 135.40–.42 (1966), with 
    id. §§ 135.40–.42
    (2006).        These
    provisions provide,
    12
    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 material, 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 proceedings 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. §§ 135.40–.42
    (2015).
    13
    B. Iowa Code Section 135.40. The first issue we must address is
    whether the PSN qualifies as a morbidity and mortality study under Iowa
    Code section 135.40.    The statute provides that an organization “may
    provide information, interviews, reports, statements, memoranda, or
    other data relating to the condition and treatment of any person . . . to be
    used in the course of any study for the purpose of reducing morbidity or
    mortality.” 
    Id. § 135.40.
    The State argues the statute is broad enough to
    encompass the PSN documents. Willard argues that there is no evidence
    in the record that the PSN was actually used in the course of any study
    for the purpose of reducing morbidity and mortality, and therefore it is
    not protected under the statute.
    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, ___ N.W.2d at ___ (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).
    14
    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 has an expansive
    scope, which is demonstrated throughout the text of section 135.40. See
    Iowa Code § 135.40. The statute relies on a broad range of organizations
    to provide information—“[a]ny person, hospital, sanatorium, nursing or
    rest home, or other organization.”      
    Id. § 135.40
    (emphasis added).    It
    allows these groups to provide a wide array of information—“information,
    interviews, reports, statements, memoranda, or other data relating to the
    condition and treatment of any person.” 
    Id. (emphasis added).
    It allows
    a wide number of organizations to be the recipient of this information—
    “the [public health] department, the Iowa medical society or any of its
    allied medical societies, the Iowa osteopathic medical association, or any
    in-hospital staff committee, or the Iowa healthcare collaborative.”      
    Id. (emphasis added).
    It allows the information provided and collected “to be
    used in the course of any study for the purpose of reducing morbidity
    and mortality.” 
    Id. (emphasis added).
    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. Iowa Admin. Code § 481—51.3.
    Hospitals are required to have a written quality improvement plan which,
    15
    among other things, may address the “accessibility and confidentiality of
    materials relating to, generated by, or [included as] part of the quality
    improvement process.”      
    Id. § 481—51.3(4)(g).
         All of this indicates a
    legislative intent to encourage a wide number of individuals and
    organizations to report incidents and concerns about patient care, in a
    wide variety of formats.
    A PSN clearly falls within the legislative intent of “any study for the
    purpose of reducing morbidity or mortality.” Iowa Code § 135.40. The
    PSN system allows the UIHC to keep track of patient incidents and to
    route them to the appropriate department for resolution.            The PSN
    system can also result in revised policies for the hospital as a whole or
    for use in studies, reports, and presentations. Similar to the purposes of
    the PSQIA, the purpose of section 135.40 is “to encourage the reporting
    and analysis of medical errors and health care systems by providing peer
    review protection of information reported to patient safety organizations
    for the purposes of quality improvement and patient safety.” 
    Tibbs, 448 S.W.3d at 801
    (quoting H.R. Rep. No. 109–197 (2005)). We find that the
    PSN and related documents are afforded a privilege as morbidity and
    mortality information to be used in a study as defined in Iowa Code
    section 135.40.
    C. Iowa Code Section 135.41.           The second issue we must
    address is whether Iowa Code section 135.41 has any applicability to the
    privilege asserted here. The district court found that the State failed to
    establish a privilege under this section because the case does not involve
    a third party being asked to produce records, but rather Willard himself
    requesting the documents.     The district court found that the privilege
    only protects against disclosures to third parties.
    16
    Iowa Code section 135.41 governs the publication of studies that
    include material regarding morbidity and mortality. 
    Id. § 135.41.
    The
    language of the statute is limiting.     It limits the use of morbidity and
    mortality information with mandatory language. 
    Id. The organizations
    authorized to use the information “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.” 
    Id. (emphasis added).
    The statute also includes a permissive clause; however, this language is
    still limiting. The organizations that publish material in the interest of
    reducing morbidity or mortality may release a summary of the study for
    general publication. 
    Id. We found
    in Burton v. University of Iowa Hosps.
    & Clinics that the hospital has the discretion to determine whether to
    produce these summaries. 
    566 N.W.2d 182
    , 187–88 (Iowa 1997).
    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 section 135.41.
    D. Iowa Code Section 135.42.           The final question we must
    answer is whether the PSN is subject to discovery under section 135.42.
    The statute provides that information obtained under the morbidity and
    mortality statutes “shall not be used or offered or received in evidence in
    any legal proceedings.”    Iowa Code § 135.42.      The State argues this
    should be interpreted to mean morbidity and mortality information
    cannot be used in any legal proceedings, including discovery. Because
    “shall not be . . . offered or received in evidence” already covers
    information utilized during trial, the State argues that any other
    17
    definition would render the words “shall not be used” superfluous, and
    therefore it should be interpreted to include discovery. Willard argues
    that while the statute provides that the documents may not be used,
    offered, or received in evidence, it does not preclude the documents from
    being discoverable.
    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, Iowa
    Rule of Civil Procedure 1.503 limits the scope of
    discovery to “any matter, not privileged, which is relevant to the subject
    matter involved in the pending action.” Iowa R. Civ. P. 1.503 (emphasis
    added). A party may resist discovery by demonstrating that the material
    sought is privileged, but the party resisting has the burden of
    demonstrating both that the privilege exists and that it applies. 
    Carolan, 553 N.W.2d at 886
    . We construe asserted privileges narrowly because a
    privilege is an exception to our generally liberal rules regarding discovery.
    
    Id. When a
    party asserts a privilege that is based on a statute, the words
    of the statute define the reach of the privilege. 
    Id. Here, the
    State has
    demonstrated that the materials are privileged as morbidity and
    mortality information under Iowa Code section 135.40.          Because the
    privilege is statutory, the words of section 135.42 define the reach of the
    privilege. 
    Id. 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
    18
    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. of Del., 
    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. Iowa Code § 135.42. In
    applying the doctrine to the statute, we find the legislature has precluded
    the   use   of   morbidity   and       mortality   information   under      three
    circumstances. The studies or information may not be: (1) used in any
    legal proceeding, (2) offered in any legal proceeding, or (3) received in
    evidence in any legal proceeding. See 
    id. Additionally, when
    a statute is ambiguous, we may consider the
    “consequences    of   a   particular     construction”   in   determining    the
    legislature’s intent. 
    Id. § 4.6(5).
    Here, there are relevant public policy
    issues to be considered.      The rationale underlying the protection of
    privileged communication from discovery “is the protection of interests
    and relationships, which rightly or wrongly, are regarded as of sufficient
    social importance to justify some sacrifice of availability of evidence
    relevant to the administration of justice.” 8 Tom Riley & Peter C. Riley,
    Iowa Practice SeriesTM, Civil Litigation Handbook, § 29:1 (2016 ed.)
    (quoting McCormick on Evidence § 72 (4th ed.)).
    The overall statutory scheme regarding morbidity and mortality
    information and studies is broad. As discussed earlier, section 135.40
    encompasses a wide number of individuals and organizations that may
    provide information and a wide number of organizations that may receive
    information. Iowa Code § 135.40. It provides that information used in
    19
    the course of any study intended to reduce morbidity and mortality rates
    is subject to its protection. 
    Id. Section 135.41
    is similarly broad in its
    protection of information related to morbidity and mortality.            
    Id. § 135.41.
    Only a summary of the studies may be released, but within
    the discretion of the organization producing the study. Id.; 
    Burton, 566 N.W.2d at 187
    –88.
    We likewise find that the legislature intended section 135.42 to
    broadly cover “any legal proceeding.”      Iowa Code § 135.42 (emphasis
    added).    There are a number of public policy objectives underlying
    morbidity and mortality statutes.        Preventable medical errors are a
    pervasive issue in hospitals across the country and decreasing the
    number of these errors is of the utmost importance. To Err Is Human, at
    26–27.    The information utilized in morbidity and mortality studies is
    collected from hospital employees and is intended to track adverse
    events; sentinel events; safety issues; and any other concerns regarding
    the health, care, and safety of patients. The objective of collecting this
    information is to study adverse incidents in order to create new systems
    and methods to prevent patient safety issues in the future.              The
    information provided is supplied by employees about their peers or
    supervisors. Morbidity and mortality studies are protected so employees
    are forthcoming with their concerns, issues, and criticisms.
    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 553 N.W.2d at 886
    , we nevertheless find the rationale
    similarly persuasive in the context of PSNs and related 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
    20
    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.
    
    Id. at 886–87.
    The same is true for PSNs and the related documents. There is a
    strong public policy argument for interpreting section 135.42 broadly.
    The protection afforded by the confidentiality privilege allows hospital
    staff to feel comfortable reporting any and all safety concerns because
    those reports will remain confidential and not be subject to discovery in a
    legal proceeding. This confidentiality allows hospitals to utilize PSNs to
    reduce adverse patient safety events based on preventable medical
    errors.    The   protection   is   intended   to   apply   to   documents   or
    communications that constitute “patient safety work product.” We find
    that Iowa Code section 135.42 extends to prevent discovery of PSNs and
    related documents.
    IV. Conclusion.
    For the above reasons, we 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 Iowa Code section 135.40.          We find that Iowa Code
    section 135.41 does not apply because Willard does not seek a summary
    of the morbidity or mortality study but rather the PSN and related
    documents themselves. Finally, we find that based upon the language
    contained in section 135.42, the PSN and related documents are not
    subject to discovery.
    REVERSED AND REMANDED.