Case Title: Riverside Hospital, Inc. v. Johnson

Citation: 

Docket Number: 060392

State: virginia

Court: Virginia Supreme Court

Date: 2006-11-03T00:00:00Z

Document:
Present:  Hassell, C.J., Lacy, Keenan, Kinser, Lemons, and 
Agee, JJ., and Carrico, S.J. 
 
RIVERSIDE HOSPITAL, INC., t/a 
RIVERSIDE REGIONAL MEDICAL  
CENTER, ET AL. 
 
v.  Record No. 060392     OPINION BY JUSTICE ELIZABETH B. LACY 
 
 
 
November 3, 2006 
 
TERRY ALLAN JOHNSON, EXECUTOR 
OF THE ESTATE OF ELAINE DUDLEY 
JOHNSON, DECEASED 
 
FROM THE CIRCUIT COURT OF THE CITY OF NEWPORT NEWS 
David F. Pugh, Judge 
 
Terry Allan Johnson, the executor of the estate of Elaine 
Dudley Johnson (the Estate), filed a motion for judgment 
against Riverside Regional Medical Center (Riverside) and its 
employee Nurse Nicole Green1 alleging that the defendants 
failed to accurately assess Elaine Dudley Johnson's risk of 
falling and then failed to institute appropriate measures to 
prevent her from falling.  A jury returned a verdict in favor 
of the Estate.  In this appeal, Riverside and Nurse Green (the 
Defendants) challenge four of the trial court's evidentiary 
rulings and a jury instruction.  For the reasons set out 
below, we conclude that there was no error in the trial 
court's rulings and, consequently, we will affirm the judgment 
of the trial court. 
                     
1 At the time of trial, Nicole Green was identified as 
Nicole Green Miles.  For purposes of this opinion we will 
refer to her as Nicole Green or Nurse Green. 
FACTS 
Seventy-nine year old Johnson was admitted to Riverside 
for "profound generalized weakness and new-onset confusion, 
disorientation, hallucinations and agitation," and 
dehydration.  Johnson suffered from lymphoma, which had been 
diagnosed ten years earlier.  Riverside staff completed an 
"Adult Data Base" form, which listed pertinent information 
about Johnson's medical history and condition.  The form also 
contained an assessment of Johnson's risk of falling based on 
several factors.  Johnson was not identified as a high fall-
risk patient, and no fall prevention procedures were initiated 
for her. 
Nurse Green testified that on October 31, 1997, she 
placed a call bell within Johnson's reach and that the top 
rails were in place on Johnson's bed.  Green did not install a 
bed alarm, which would have sounded had Johnson gotten out of 
bed unassisted.  Rather, Green testified that she instructed 
Johnson not to get out of bed without assistance, but to use 
the call system to request assistance in getting up. 
Sometime after 10:00 p.m. on October 31, 1997, Johnson 
fell in the hallway outside her room.  After the fall, Johnson 
complained of pain in her left hip.  An x-ray on November 1, 
1997 revealed that Johnson's left hip was fractured. 
 
2
Several months later, Johnson died of lymphoma.  The 
Estate filed suit against Nurse Green and Riverside, seeking 
$1 million in compensatory damages and $350,000 in punitive 
damages.  In the Motion for Judgment, the Estate alleged that 
although Riverside was aware of numerous patient falls, it 
failed to "implement restraints, bottom bed rails or even a 
bed check alarm" for Johnson.  The Estate further alleged that 
Riverside was negligent in, inter alia, failing to (1) assess 
Johnson as a high fall-risk patient; (2) initiate a fall 
prevention plan; and (3) utilize a prompt and reliable nurse 
call system. 
The Estate nonsuited the punitive damages claim following 
the close of evidence.  A jury returned a verdict for the 
Estate and against Nurse Green and Riverside in the amount of 
$1 million, with interest from October 31, 1997.  The court 
removed the interest award and entered a $1 million judgment 
for the Estate. 
The Defendants timely filed this appeal, raising five 
assignments of error challenging the trial court's rulings 
primarily related to the admission of evidence.  The Defendants 
claim the trial court erred in admitting statistical evidence 
concerning patient falls at other, non-party institutions and 
previous patient falls at Riverside Hospital, in admitting 
evidence of Riverside Hospital's staff-orientation instructions 
 
3
and nurse training materials from non-party Riverside School of 
Professional Nursing, in admitting privileged communications 
and reports, and in limiting testimony of the Defendants' 
standard of care expert.  The Defendants also claim that the 
trial court erred in submitting a jury instruction containing 
an incorrect statement of law.  We will consider these issues 
in order. 
DISCUSSION 
I.  ADMISSION OF STATISTICAL EVIDENCE 
In their first assignment of error, the Defendants 
challenge the trial court's decision to admit statistical 
evidence consisting of information from bar graphs contained 
in a nursing journal article and information kept and compiled 
by Riverside regarding other patient fall cases at Riverside.  
Our review of the record, as discussed below, shows that the 
Defendants failed to preserve their objections to this 
evidence. 
A.  BAR GRAPH CHARTS 
During opening statements, the Estate showed the jury bar 
graphs displaying various information about patient falls in 
the general hospital population, and referred to the 
information on the graphs.  The Defendants objected, stating 
that although the graphs could be properly relied on by 
experts and read to the jury pursuant to Code § 8.01-401.1, 
 
4
the graphs and articles were "not evidence and [it was] 
certainly impermissible to argue to the jury statistics in 
this case."  The trial court overruled the objection. 
Nurse Wendy E. Jenvey, the Estate's expert witness, then 
testified that the journal article containing the bar graphs 
was the type of source normally relied upon by others in the 
nursing field to form opinions, and that she considered the 
article to be a reliable authority.  Jenvey described the 
content of the article and the graphs to the jury.  The 
Defendants did not object to this testimony.  The Estate again 
referred to information in the bar graphs during closing 
argument, again without any objection from the Defendants.  
Although shown to the jury, neither the journal article nor 
the bar graphs were introduced into evidence. 
In the absence of any objection to the bar graph 
references during Jenvey's testimony or closing arguments, 
only the Estate's reference to the bar graphs made in opening 
argument is before us in this assignment of error.  Rule 5:25.  
In objecting to statements made in the opening argument, the 
Defendants argued that the bar graphs and journal article were 
"not evidence" and that arguing such statistics to the jury 
was "impermissible."  The assignment of error challenges the 
admission of evidence; however an opening statement is 
argument of counsel, and does not involve admission of 
 
5
evidence.  To the extent the assignment of error addresses the 
propriety of the Estate's argument and the trial court's 
determination that including reference to the bar graphs was 
permissible, that ruling, if error, is harmless error.  As the 
record reflects, the jury heard the same information during 
Jenvey's testimony without objection. 
B.  RIVERSIDE HOSPITAL PATIENT FALL REPORTS 
The Defendants next contend that the trial court erred in 
admitting statistical evidence about other patient falls at 
Riverside (the Fall Evidence).  This evidence consisted of 
testimony based on a report generated by Riverside listing 
patient fall data from January through October 1997. 
In a pre-trial motion in limine, the Defendants argued 
that this information was irrelevant, prejudicial, and likely 
to confuse and mislead the jury.  The Estate countered that 
the information was relevant to establishing notice under the 
punitive damage claim.  The trial court agreed with the Estate 
and ruled that patient falls which took place after the 
patient had gotten out of bed were similar to Johnson's fall, 
and that data about those falls was admissible for purposes of 
notice for the punitive damage claim.  The trial court 
suggested that a cautionary instruction could be given to the 
jury to clarify the purpose of such information. 
 
6
At the close of evidence, the Estate nonsuited the claim 
for punitive damages.  The Defendants did not renew their 
objection to the Fall Evidence on the basis of relevance, and 
did not ask for any cautionary jury instruction regarding 
consideration of the Fall Evidence.  The Estate maintains that 
the Defendants waived their objection to the Fall Evidence 
because they did not renew their relevancy objection following 
the nonsuit of the punitive damage claim.  The Defendants 
contend that once they noted their exception to the denial of 
their motion in limine, they were not obligated to renew their 
objection to the Fall Evidence. 
The purpose of Rule 5:25 is to afford the trial court the 
ability to address an issue.  If that opportunity is not 
presented to the trial court, there is no ruling by the trial 
court on the issue, and thus no basis for review or action by 
this Court on appeal.  Furthermore, Rule 5:25 requires that 
parties state objections with "reasonable certainty."  See 
Fisher v. Commonwealth, 236 Va. 403, 413-14, 374 S.E.2d 46, 52 
(1988) (holding defendant had waived objection pursuant to 
Rule 5:25 by offering a general objection that "failed to put 
the trial court on fair notice"). 
In this case, the Defendants, in their pre-trial motions 
and during Friend's testimony, clearly objected to the 
admission of the Fall Evidence as irrelevant, immaterial and 
 
7
confusing or prejudicial to either the issue of notice or 
negligence.  The trial court allowed the Fall Evidence for the 
purpose of notice; however, the punitive damage claim 
ultimately was not presented to the jury.  Although the 
Defendants are correct that they did not have to renew their 
objection to the introduction of the Fall Evidence as it 
related to the notice claim,2 under the circumstances of this 
case, we conclude that the Defendants' failure to reassert 
their objection that the Fall Evidence was irrelevant to the 
issue of negligence, or to ask the trial court to give the 
jury a cautionary instruction regarding the use of such 
evidence, precluded the trial court from considering whether 
further action or ruling should be made regarding that 
evidence after the Estate's punitive damages claim was 
nonsuited. 
In Riner v. Commonwealth, 268 Va. 296, 601 S.E.2d 555 
(2004), the defendant did not object when the trial court took 
defendant's pre-trial motion for change of venue under 
advisement.  We held that because the defendant did not renew 
                     
2 The punitive damage claim was not submitted to the jury.  
Therefore, a ruling by this Court on whether the admission of 
the evidence for purposes of notice was error would be an 
advisory opinion because our ruling would not have any effect 
on the verdict that was rendered.  This Court does not issue 
advisory opinions.  Commonwealth v. Harley, 256 Va. 216, 219, 
504 S.E.2d 852, 854 (1998); City of Fairfax v. Shanklin, 205 
Va. 227, 229-30, 135 S.E.2d 773, 775-76 (1964). 
 
8
the motion or remind the court that the motion was still 
pending prior to the seating of the jury, the change of venue 
motion was waived and could not be raised on appeal.  Id. at 
309-310, 601 S.E.2d at 562-63. 
In this case, while the trial court did not take under 
advisement the Defendants' objection to the admission of the 
Fall Evidence as irrelevant and prejudicial to the negligence 
issue, the court also did not specifically address this 
objection in ruling that the evidence could be admitted for 
the limited purpose of notice in connection with the punitive 
damage claim.3  When the punitive damage claim was nonsuited, 
the complexion of the litigation changed significantly.  The 
Defendants recognized this change and sought to strike 
portions of the motion for judgment relating to the punitive 
damage claim and co-authored a joint statement read to the 
jury explaining that punitive or exemplary damages were no 
longer part of the litigation.  They took no steps, however, 
to bring to the attention of the trial court the irrelevance 
of the Fall Evidence in light of the changed circumstances of 
the case, nor did they seek a cautionary instruction regarding 
                     
3 Implicit in the limitation of the use of the Fall 
Evidence to the notice issue, is the proposition that the 
evidence was not relevant to other issues.  However, 
Defendants have characterized the trial court's ruling as 
denying their objection to the evidence with regard to the 
negligence issue. 
 
9
the jury's use of that evidence.  Thus, as in Riner, the 
Defendants did not afford the trial court in this case an 
opportunity to rule on their objections to the Fall Evidence 
in the sole context of the negligence issue. 
We reject the Defendants' argument that they renewed 
their relevance objection by moving to strike portions of the 
Motion for Judgment affected by the nonsuit.  Nothing in this 
motion referred to either the statistical evidence of which 
they now complain or to its relevance to the negligence count.  
Thus, this motion also fails to meet the "reasonable 
certainty" requirement contained in Rule 5:25. 
For these reasons we conclude that the Defendants did not 
preserve their objections to the statistical evidence 
involving patient falls at other hospitals and at Riverside 
Hospital and we will not consider this assignment of error 
further.  Rule 5:25. 
II.  ADMISSION OF ORIENTATION INSTRUCTIONS  
AND NURSE TRAINING MATERIALS 
 
The Defendants next assign error to the trial court's 
decision to admit evidence of Riverside's staff orientation 
instructions and nurse training materials from the Riverside 
School of Professional Nursing. 
In pre-trial motions, the Estate sought discovery of 
Riverside orientation materials on high fall-risk assessment 
 
10
or prevention and nurse training materials on that subject 
from Riverside School of Professional Nursing, arguing such 
information was relevant to notice under the punitive damage 
claim and to the standard of care.  The trial court granted 
the Estate's motions to compel over the Defendants' objection. 
Following discovery, the Defendants filed a motion in 
limine again arguing that the orientation material and nursing 
school curriculum should not be admitted because they 
constituted private rules which cannot establish the standard 
of care, were otherwise irrelevant, and would be confusing to 
the jury.  In response, the Estate asserted that these 
materials were not policies and procedures of the hospital, 
and would not be offered as the standard of care.  The Estate 
maintained that standard of care testimony would come only 
from an expert, that the materials were relevant as 
establishing education, and would be "corroborative" of the 
expert's standard of care testimony.  The trial court denied 
the Defendants' motion in limine. 
 
At trial, the Defendants again objected to the admission 
of the orientation and nursing school curriculum evidence when 
offered through the testimony of Flo A. Hicks and Debra 
Sullivan-Yates, respectively.  The Estate again asserted that 
the evidence was not introduced as the standard of care, but 
 
11
as foundation and corroboration of its expert's testimony.4  
The trial court allowed the testimony of both witnesses. 
We review a trial court's evidentiary rulings applying an 
abuse of discretion standard.  We will not overturn a trial 
court's exercise of its discretion in determining whether to 
admit or exclude evidence on appeal unless the evidence shows 
that the trial court abused its discretion.  Hinkley v. 
Koehler, 269 Va. 82, 91, 606 S.E.2d 803, 808 (2005).  While a 
"trial court has no discretion to admit clearly inadmissible 
evidence," Norfolk & Western Ry. Co. v. Puryear, 250 Va. 559, 
563, 463 S.E.2d 442, 444 (1995) (quoting Coe v. Commonwealth, 
231 Va. 83, 87, 340 S.E.2d 820, 823 (1986)), "a great deal 
must necessarily be left to the discretion of the court of 
trial, in determining whether evidence is relevant to the 
issue or not."  Peacock Buick, Inc. v. Durkin, 221 Va. 1133, 
1136, 277 S.E.2d 225, 227 (1981) (internal quotation marks 
omitted). 
 
We first address the Defendants' arguments that, pursuant 
to Virginia Ry. & Power Co. v. Godsey, 117 Va. 167, 83 S.E. 
1072 (1915) and Pullen v. Nickens, 226 Va. 342, 310 S.E.2d 452 
(1983), the evidence at issue was inadmissible because it 
                     
4 The Defendants also argued that the material was 
inadmissible because there was no evidence that Nurse Green 
attended the Riverside School of Nursing or that she saw the 
 
12
served as private rules, which cannot establish the standard 
of care.  We reject this argument for two reasons.  First, 
Godsey and Pullen involved policies and procedures that 
employees were expected to follow and as such were described 
as "private rules."  Godsey, 117 Va. at 168-70, 83 S.E. at 
1072-73; Pullen, 226 Va. at 349-51, 310 S.E.2d at 456-57.  In 
this case, the evidence of the staff orientation instruction 
and nursing curriculum, although dealing with the issue of 
fall-risk assessment and prevention, were not hospital 
policies or procedures of the type involved in Godsey and 
Pullen.  More importantly, it was clear throughout this 
proceeding that the trial court ruled, and the Estate agreed, 
that the evidence in question would not be admitted to 
establish the standard of care.  That limitation was repeated 
during the admission of the evidence and the jury was 
instructed that the standard of care for Nurse Green's actions 
could be established only through expert testimony. 
In addition, the Estate's expert witness, Jenvey, 
testified that the orientation material and nursing 
instruction were among the materials she consulted in 
formulating her opinion on the standard of care.  The 
Defendants did not object to Jenvey's reference to and 
                                                                
orientation video.  In light of our disposition of this issue, 
we need not address that objection. 
 
13
reliance on this evidence.5  Furthermore, Nurse Green, who 
testified after Hicks and Sullivan-Yates, and before Jenvey, 
stated that she had attended the Riverside orientation, 
described the contents of the orientation, and testified that 
her nursing education entailed a "general nursing curriculum." 
Considering this record, we cannot say the trial court 
abused its discretion in admitting evidence of Riverside's 
orientation materials and the nursing school curriculum on 
high fall-risk assessment and prevention.  Under the trial 
court's rulings, the evidence at issue was not offered to 
establish the standard of care.  Rather, the jury was 
instructed to rely on the expert testimony regarding the 
standard of care.  There was no objection to the relevancy of 
the evidence when the Estate's expert testified she referred 
to it in formulating her opinion on the standard of care, and 
similar evidence was admitted through the testimony of Nurse 
Green. 
III.  ADMISSION OF QUALITY CARE CONTROL REPORT  
AND INFORMATION FROM HOSPITAL FALL DATABASE 
 
 
We next turn to the Defendants' contention that the trial 
court erred in admitting into evidence certain reports made 
and maintained by Riverside because they were privileged 
                     
5 The Defendants' only objection to this testimony was 
that some of the materials Jenvey identified as credible 
 
14
documents pursuant to Code § 8.01-581.17.  Over the Defendants' 
objection, the trial court admitted into evidence a document 
which Riverside termed a Quality Care Control Report (QCCR).  
This report consists of a form onto which Green had entered 
information about Johnson's fall.  In the blocks provided, 
Green indicated the date, place, and time of the fall, the 
severity of the fall, the facts of the fall, whether the 
patient was aware of the fall and her reaction to it, and her 
status before the fall including the use of any restraints, 
side rails, or call bell.  The trial court also admitted a 
redacted page from Riverside's Quality Management Services 
(QMS) database report.  This page contained entries about 
Johnson's fall, as well as that of a 61 year-old Riverside 
patient who fell the same day as Johnson.6
Joanne Friend, Riverside's Director of Risk Management, 
testified that the QCCR is an incident report that Green 
                                                                
authority for determining the standard of care were not 
contained in the designation submitted pre-trial. 
6 The entry about Johnson stated in relevant part:  
"Patient was found on the floor in the hallway; had 
gotten OOB [out of bed] without assistance – 
unsteady gait/confused.  Patient c/o left hip pain 
after fall."  The entry about the other patient 
stated:  "Patient was found on the floor of the 
doorway to his room with IV pole in hand.  The 
patient states he can't remember why he got OOB, and 
he did not hurt himself.  Pt. stated that he 'got 
down on his L knee and crawled to the door.' . . .  
ACTIONS:  Bedcheck on; nurse call system down.  
Patient refuses restraints . . . ." 
 
15
prepared "in the course of her job."  Such reports, Friend 
stated, were completed for all falls regardless of whether 
there was an injury or litigation was expected.  Friend 
testified that after the QCCRs were completed, some of the 
information on the forms would be entered into the QMS 
database by an employee in Friend's office.  The QCCRs were 
generally destroyed after three months, although Friend 
retained the QCCR describing Johnson's fall in anticipation of 
litigation.  Reports were generated based on the information 
in the QMS database and those reports were provided to 
Riverside's "quality committee which was made up of 
administrators and physicians," and then ultimately to 
Riverside's board of directors.  Not every report was given to 
the hospital's quality committee, but the information 
contained in the reports was always available to committee 
members.7  According to Friend, QCCR's were generated for the 
purpose of "improvement efforts." 
The Defendants argue that the information on the QCCR was 
a qualitative analysis of Johnson's fall and that the QMS 
database is a digest of QCCR forms intended to improve the 
delivery of healthcare at Riverside.  As such, the Defendants 
                     
7 It is not clear from the record whether the specific 
QCCR at issue was given to a peer review or quality care 
committee, although it is clear that some information from the 
 
16
contend, the information was privileged material, exempt from 
disclosure under Code § 8.01-581.17. 
The Estate replies that the reports at issue were 
actually routine accident reports that were designated as 
quality care control documents in an attempt to invoke the 
privilege afforded under Code § 8.01-581.17(B).  According to 
Johnson, neither the QCCR nor the page from the QMS database 
contains any qualitative information about either fall 
incident, only the circumstances of the falls.  Such 
information, the Estate argues, should not be entitled to the 
privilege under Code § 8.01-581.17 merely because it may be 
ultimately reviewed by a medical staff, quality assurance, 
peer review, or other type of committee identified in the 
statute.  The incident reports or QCCR's and the database 
report made from those reports are medical records kept in the 
course of operating a hospital and thus under Subsection (C) 
of Code § 8.01-581.17 are not entitled to the presumption, 
according to the Estate. 
As relevant here, Code § 8.01-581.17 provides as follows:8
B. 
The proceedings, minutes, records, and 
reports of any (i) medical staff committee, 
utilization review committee, . . . (iii) quality 
assurance, quality of care, or peer review 
                                                                
QCCR would be contained in reports given to various quality 
review committees. 
8 Code § 8.01-581.17 was amended in 2006 but those 
amendments are not relevant to the issues in this appeal. 
 
17
committee . . ., together with all communications, 
both oral and written, originating in or provided 
to such committees . . . are privileged 
communications which may not be disclosed or 
obtained by legal discovery proceedings unless a 
circuit court, after a hearing and for good cause 
. . . orders the disclosure of such proceedings, 
minutes, records, reports, or communications. . . . 
Oral communications regarding a specific medical 
incident involving patient care, made to a quality 
assurance, quality of care, or peer review 
committee established pursuant to clause (iii), 
shall be privileged only to the extent made more 
than 24 hours after the occurrence of the medical 
incident. 
C. 
Nothing in this section shall be 
construed as providing any privilege to health care 
provider . . . medical records kept with respect to 
any patient in the ordinary course of business of 
operating a hospital . . . nor to any facts or 
information contained in such records nor shall 
this section preclude or affect discovery of or 
production of evidence relating to hospitalization 
or treatment of any patient in the ordinary course 
of hospitalization of such patient. 
 
The documents at issue are not documents generated by a 
peer review or other quality care committee referred to in the 
statute.  Thus they are not proceedings, minutes, reports, or 
other communications "of" or "originating in" such committees.  
The question is whether they qualify for the privilege because 
they are "communications . . . provided to" such peer review 
or quality care committees. 
A literal application of the phrase "all communications, 
both oral and written, . . . provided to such committees" 
would impress the privilege on every document and every 
statement made available to a committee or entity identified 
 
18
in the statute.  Such an application would allow a health care 
facility to immunize from disclosure every statement or 
document maintained by the facility simply by insuring that 
such statement or document was provided or available to a peer 
or quality review committee.  Considering this phrase in the 
context of the entire section, however, shows that the General 
Assembly did not intend such a broad application of the 
privilege.  For example, the privilege attaching to oral 
communications regarding a specific medical incident involving 
patient care is limited.  Code § 8.01-581.17(B).  Similarly, 
the section is not to "be construed" as applying the privilege 
to the facility's medical records of a specific patient kept 
in the ordinary course of operating such facility, or to 
evidence of a patient's treatment or hospitalization kept in 
the ordinary course of the patient's hospitalization.  Code 
§ 8.01-581.17(C). 
These limitations on the application of the privilege are 
consistent with preserving the confidentiality of the quality 
review process while allowing disclosure of relevant 
information regarding specific patient care and treatment.  
"The obvious legislative intent [of the statute] is to promote 
open and frank discussion during the peer review process among 
health care providers in furtherance of the overall goal of 
improvement of the health care system.  If peer review 
 
19
information were not confidential, there would be little 
incentive to participate in the process."  HCA Health Services 
of Virginia, Inc. v. Levin, 260 Va. 215, 221, 530 S.E.2d 417, 
420 (2000).  It is the deliberative process and the 
conclusions reached through that process that the General 
Assembly sought to protect.  See Code § 8.01-581.16 (providing 
immunity for actions taken by persons involved in the peer 
review process).  
The deliberative process involving evaluation of patient 
safety conditions and the design of initiatives to improve the 
health care system both necessarily begin with factual 
information of patient care incidents occurring within the 
health care facility.  The use of this factual information in 
some way in the peer review or quality care committee process 
alone is insufficient to automatically cloak such information 
with the protection of non-disclosure.  Factual patient care 
incident information that does not contain or reflect any 
committee discussion or action by the committee reviewing the 
information is not the type of information that must 
"necessarily be confidential" in order to allow participation 
in the peer or quality assurance review process.  Rather such 
information is the type, contemplated by Subsection (C) of 
Code § 8.01-581.17, which the General Assembly has 
specifically instructed should not be brought within the scope 
 
20
of those items entitled to the privilege under any other part 
of the section.9
Applying these principles, we conclude that the documents 
at issue here are of the nature of those described in Code 
§ 8.01-581.17(C) and are not privileged.  The QCCR, or 
incident report, was a written documentation of the 
circumstances of Johnson's fall, kept in the normal course of 
business.  The QCCR was a factual recitation of a fall that 
occurred during Johnson's hospitalization and the immediate 
action taken when Johnson was found on the floor.  Likewise, 
the redacted page from the QMS database report was a factual 
description of Johnson's fall and that of another patient 
which, according to Friend's testimony, was based on a QCCR.  
Like the QCCR, the information on this page related to the raw 
data about the hospitalization and treatment of specific 
patients.10   Both documents were medical records of the 
hospital, made and kept in the normal course of the operation 
of the hospital.  Accordingly, the trial court did not err in 
                     
9 The Defendants argue that such records must be the 
medical chart of the specific patient.  However, the statute 
refers to medical records of the health care facility.  Thus, 
this provision is not limited to what is contained in the 
documents generally considered to be the patient's medical 
chart. 
10 Our consideration here is limited to the specific 
entries contained on this page and not to a QMS database 
report in general.  
 
21
ruling that the documents were not privileged pursuant to the 
statute. 
IV.  TESTIMONY OF NURSE FRANCIS A. VICKERS 
 
At trial, the Defendants proffered Nurse Francis A. 
Vickers as an expert to testify about assessing patient fall-
risk and risk-reducing interventions.  The Estate argued that 
because Vickers had not had experience in activating bed 
alarms, she did not fulfill the active clinical practice 
requirement for a testifying expert.  Code § 8.01-581.20.  The 
trial court agreed with the Estate and allowed Vickers to 
testify about fall-risk assessment and fall-risk intervention 
measures other than bed alarms.  The Defendants, after 
objecting to the court's ruling, indicated that they wished to 
avoid telling the jury that Nurse Vickers was not qualified to 
testify on bed alarms, and ultimately offered Nurse Vickers as 
an expert only in patient fall-risk assessment.  Nurse Vickers 
testified that Johnson was not a high fall-risk patient.  
On appeal, the Defendants present the following 
assignment of error:  
The trial court erred in prohibiting 
defendants' standard of care expert, Nurse Francis 
Vickers, from testifying that Ms. Johnson did not 
require fall-prevention measures because she was 
not a high-fall-risk patient. 
 
It is not clear from this assignment of error exactly which 
ruling of the trial court the Defendants challenge.  This 
 
22
assignment of error does not address the limitation the trial 
court placed on Nurse Vickers' qualification as an expert.  
Nor does this assignment of error challenge Vickers' ability 
to testify on fall-risk assessment, because she did present 
such testimony.  And although she did not present testimony on 
fall prevention measures other than bed alarms, she was 
entitled to do so.  Furthermore, the Defendants' counsel 
agreed that Vickers could not be asked whether "any 
intervention" was necessary because a negative answer, based 
on Vickers' opinion that Johnson was not a high fall-risk 
patient, would imply that Vickers had also excluded bed 
alarms, a subject about which she was not qualified to 
testify. 
On brief here, the Defendants assert that Vickers should 
have been allowed to testify as to the need for initiation of 
fall prevention measures, regardless of the nature of the 
types of fall prevention interventions.  We do not find any 
ruling of the trial court, however, specifically prohibiting 
such testimony.  Rather, the trial court ruled that the 
Defendants could not question Vickers about the need for "any 
intervention," without indicating that the question was not 
meant to include bed alarms.  Furthermore, implicit in Nurse 
Vickers' opinion that Johnson was not a high fall-risk patient 
is the conclusion that, therefore, fall-risk prevention 
 
23
measures were not necessary.  For these reasons, we reject 
this assignment of error. 
V.  JURY INSTRUCTIONS 
In their final assignment of error, the Defendants assert 
that the jury verdict must be set aside because of an error of 
law in a jury instruction and the resulting jury confusion. 
The jury received the following instructions: 
Instruction 14:  The Court instructs the jury that 
a hospital has the duty to exercise reasonable care 
and attention for a patient's safety as her mental 
and physical condition, if known, may require. 
 
If a hospital fails to perform this duty, then it 
is negligent. 
 
Instruction 15:  The Court instructs the jury that 
a nurse has a duty to use the degree of skill and 
diligence in the care and treatment of her patient 
that a reasonably prudent nurse in the same field 
of practice or specialty in this State would have 
used under the circumstances of this case.  If 
Nurse Green and/or any other Riverside nurse failed 
to perform that duty . . . then each such nurse and 
Defendant, Riverside, is negligent. 
 
Instruction 18:  The Court instructs the jury that 
you must determine the degree of care that was 
required of Defendant, Riverside, Nurse Green, 
and/or Riverside's other nurses by considering only 
the expert testimony on that subject. 
 
The Defendants argue that Instruction 14 was improper 
because it failed to inform the jury of the correct negligence 
standard to be applied to a hospital in a medical malpractice 
case.  The Defendants claim Instruction 14 improperly told the 
jury to determine the standard of care based on common 
 
24
knowledge.  Rather, the standard of care should be determined 
by expert testimony on the issue.  Perdieu v. Blackstone 
Family Practice Ctr., 264 Va. 408, 422, 568 S.E.2d 703, 711 
(2002) ("Furthermore, the appropriate standard of care 
required by a nursing home to prevent falls by residents is 
not within the common knowledge or understanding of a jury."). 
The Defendants further argue that Instruction 14 misled 
and confused the jury.  During deliberations, the jury asked 
if it could find the hospital negligent without finding Nurse 
Green negligent.  The Defendants claim that the jury's 
question evidences confusion as to the interplay between 
Instruction 14 and Instructions 15 and 18.  Citing Blue Stone 
Land Co. v. Neff, 259 Va. 273, 526 S.E.2d 517 (2000), the 
Defendants argue that because the harmless error doctrine is 
never applied when the jury has been erroneously instructed, 
the jury's verdict must be set aside and the case remanded. 
This Court has often found that where an erroneous 
instruction conflicts with an instruction that correctly 
states the law, the verdict must be set aside because it is 
impossible to determine which instruction was the basis for 
the jury's decision.  See, e.g., Doe v. Scott, 221 Va. 997, 
1002-03, 277 S.E.2d 159, 162-63 (1981) (reversing due to 
instruction that incorrectly stated statutory duty); Redd v. 
Ingram, 207 Va. 939, 942, 154 S.E.2d 149, 152 (1967) (setting 
 
25
aside jury verdict because even though erroneous instruction 
was counterbalanced by correct instruction, "we cannot know 
whether the jury followed [the erroneous] Instruction E(1) or 
[the correct] Instruction 2."); American Locomotive Co. v. 
Whitlock, 109 Va. 238, 243, 63 S.E. 991, 993 (1909)("The fact 
that [Instruction] No. 4 correctly stated the law does not 
cure the error of No. 1, which was a complete instruction in 
itself, and may have controlled the jury in their finding."). 
 
Nevertheless, a jury verdict based on an erroneous 
instruction need not be set aside if it is clear that the jury 
was not misled.  Shifflett v. Commonwealth, 221 Va. 191, 194, 
269 S.E.2d 353, 355 (1980)(error in instruction cured by other 
instructions given); Tolston v. Reeves, 200 Va. 179, 183, 104 
S.E.2d 754, 757 (1958)(instruction which misstates the law may 
be cured by a correct statement of the law in a separate 
instruction if it "plainly appears that the jury could not 
have been misled by the defective instruction"). 
 
Applying these principles, we conclude that, assuming 
without deciding that Instruction 14 was an erroneous 
statement of the law, such error does not require the jury 
verdict be set aside in this case.  Instructions 15 and 18 set 
out the proper standard for determining Nurse Green's 
negligence.  Thus the jury's verdict against Nurse Green was 
based on correct instructions. 
 
26
Instruction 15 also stated, correctly, that if the jury 
found Nurse Green negligent, then Riverside also was 
negligent.  "A jury is presumed to follow its instructions."  
Weeks v. Angelone, 528 U.S. 225, 234 (2000).  Therefore, 
having found Nurse Green negligent, a verdict against 
Riverside was required based Instruction 15.  Because 
Instruction 15 ensured that the jury was not misled with 
respect to finding Riverside negligent, Tolston, 200 Va. at 
183, 104 S.E.2d at 757, any error in Instruction 14 would not 
require that the verdict be set aside. 
For the reasons stated, we find no error in the rulings 
of the trial court.  Thus, we will affirm the judgment of the 
trial court. 
Affirmed.  
JUSTICE AGEE, with whom JUSTICE KEENAN joins, concurring in 
part and dissenting in part. 
 
I agree with the majority opinion except as to Part I.B., 
which holds that Rule 5:25 applies to the Defendants’ 
assignment of error on the admission of statistical evidence 
of other falls at Defendants’ hospital (“Fall Evidence”).  The 
majority opines in Part I.B. that Rule 5:25 required 
Defendants to reassert their prior objection to the Fall 
Evidence on the basis of relevance, or to ask the trial court 
to give the jury a cautionary instruction regarding the use of 
 
27
such evidence, once the Estate nonsuited its punitive damages 
claim.  In my view, the Defendants correctly and adequately 
objected to the admission of the Fall Evidence, and Rule 5:25 
does not apply.  Further, I would find the trial court erred 
in denying Defendants’ objections to the Fall Evidence, which 
requires reversal of the judgment of the trial court. 
Under Rule 5:25, we must examine whether an objection was 
made “with reasonable certainty” and that the objection was 
made “at the time of the ruling.”  My review of the record 
indicates the Defendants did so. 
The Defendants first objected to the Fall Evidence in 
their motion in limine.  The objection was clear, unequivocal 
and not limited to the “notice” argument on punitive damages, 
but went to the underlying negligence claim on the merits: 
[s]uch evidence is irrelevant, immaterial, likely to 
confuse and/or prejudice the jury, and should therefore 
be excluded in its entirety. 
. . . . 
Evidence of any previous falls is also misleading 
and confusing, because absent specific context, 
allowing the jury to hear such evidence could lead the 
jury to believe that a “patient fall” equals 
“negligence.” 
At the pre-trial hearing on the motion in limine, 
Defendants again objected to the relevance of the Fall 
Evidence and noted an exception to the trial court’s ruling to 
admit the evidence.  Although the trial court offered to 
 
28
consider a cautionary instruction, it ruled the Fall Evidence 
would be admissible at trial. 
When the Fall Evidence was offered at trial during the 
testimony of Joanne Friend, the Defendants again objected to 
its receipt for any purpose: “to show the jury the raw number 
of falls it’s absolutely without any context whatsoever.  It’s 
confusing, it’s misleading and reversible error, and I object 
to it.”  The Defendants then offered, and the Estate agreed to 
a “continuing objection” to avoid recurring argument during 
trial over whether the Fall Evidence was admissible.  The 
Estate thereafter took a nonsuit as to its claim for punitive 
damages, thereby removing the argument that the narrow purpose 
of showing “notice” legitimized the introduction of the Fall 
Evidence. 
The majority agrees that the Defendants, in their pre-
trial motions and during Friend’s testimony, “clearly objected 
to the Fall Evidence as irrelevant, immaterial and confusing 
or prejudicial to either the issue of notice or negligence” 
(emphasis added).  However, the majority holds today that 
Defendants nonetheless waived their argument on appeal by not 
objecting yet again after the Estate nonsuited the punitive 
damages claim, citing as authority Riner v. Commonwealth, 268 
Va. 296, 601 S.E.2d 555 (2004).  I disagree with the 
 
29
majority’s conclusion and think Riner is distinguishable on 
this point. 
Code § 8.01-384 provides, in pertinent part, “it shall be 
sufficient that a party, at the time the ruling or order of 
the court is made or sought, makes known to the court the 
action which he desires the court to take or his objections to 
the action of the court and his grounds therefor.”  The 
Defendants fulfilled this statutory requirement by at least 
three times objecting to the admission of the Fall Evidence 
for any purpose and letting the trial court know the action 
desired: exclusion of the evidence.  The objections were not 
limited to the use of such evidence on the issue of notice, 
but plainly also went to its use for any purpose on the 
underlying claim of negligence.  Nothing further was required, 
particularly in view of the Estate’s acquiescence to the 
Defendants’ “continuing objection.” 
Had the Defendants’ objections been limited to the notice 
aspect, I would agree with the majority’s analysis.  However, 
it seems clear the Defendants’ primary objection was the 
confusing and misleading information that the Fall Evidence 
could become to the jury on the fundamental issue of 
negligence. 
 
30
In my view, the holdings cited from Riner are inapposite 
to the case at bar.1  In Riner, we held as barred by Rule 5:25 
a defendant’s claim on appeal that the trial court erred in 
failing to grant a change of venue motion.  Riner, 268 Va. at 
310, 601 S.E.2d at 562-63.  However, the trial court had taken 
the motion under advisement, without objection from the 
defendant, and did not rule prior to the conclusion of trial.  
Id. at 307-09, 601 S.E.2d at 561-62.  We applied Rule 5:25 to 
the defendant’s failure to raise the lack of ruling on the 
venue issue to the trial court’s attention.  We similarly held 
as to defendant’s separate failure to remind the trial court 
it had not ruled on a part of defendant’s objection to certain 
hearsay evidence as a waiver of that claim under Rule 5:25.  
Id. at 310-11, 324-25, 601 S.E.2d at 562-63, 570-71. 
In contrast to Riner, the trial court in the case at bar 
did not take Defendants’ multiple objections to the Fall 
                     
1 The Estate also cites Green v. Commonwealth, 266 Va. 81, 
580 S.E.2d 834 (2003) and Breard v. Commonwealth, 248 Va. 68, 
445 S.E.2d 670 (1994), for the proposition that Defendants 
here waived an objection under Rule 5:25 to the admission of 
the Fall Evidence.  However, these cases are no more on point 
than Riner.  Green, like Riner, involved the defendant’s 
challenge to venue and subsequent failure to renew an 
objection after the trial court took the matter under 
advisement and later empanelled the jury.  Green, 266 Va. at 
95, 580 S.E.2d at 842.  Breard also involved a trial court’s 
invitation to a defendant, and the defendant’s subsequent 
failure to renew an objection, after the court denied the 
motion to strike a juror "for the moment" but offered to 
 
31
Evidence under advisement or fail to rule on those objections.  
The trial court clearly ruled by denying Defendants’ 
objections each time.  The Defendants did exactly what Code 
§ 8.01-384 and Rule 5:25 required.  They made clear, precise 
and timely objections, which went specifically to the issue of 
negligence and were not limited to the punitive damages claim. 
The majority opinion does not address whether the Fall 
Evidence was admissible for purposes of establishing notice as 
an element of the Estate’s punitive damages claim.  However, 
even if one assumes the Estate could make its argument as to 
notice, that does not negate the otherwise valid and timely 
objection of the Defendants to admission of the Fall Evidence 
for any purpose on the basic issue of negligence. 
We have held that raw statistical evidence is not 
probative of any issue in a medical malpractice case and 
should not be admitted.  Holley v. Pambianco, 270 Va. 180, 
185, 613 S.E.2d 425, 428 (2005).  See also McCloud v. 
Commonwealth, 269 Va. 242, 259, 609 S.E.2d 16, 25 (2005) 
(evidence of a raw number of events, without describing their 
circumstances, can be misleading or confusing to the jury); 
Sanitary Grocery Co. v. Steinbrecher, 183 Va. 495, 499-500, 32 
S.E.2d 685, 686-87 (1945) (evidence that 1,000 customers per 
                                                                
rehear the motion upon completion of voir dire.  Breard, 248 
Va. at 80, 445 S.E.2d at 677-78. 
 
32
day visited grocery store without injury inadmissible as 
misleading and throwing no light upon the facts of the case 
before the jury).   Likewise, evidence of prior, similar acts 
confuses the jury and is not relevant to prove negligence.  
See, e.g., Stottlemyer v. Ghramm, 268 Va. 7, 13, 597 S.E.2d 
191, 194 (2004) (holding “specific acts of bad conduct or 
prior acts of negligence” are not relevant to the issues in a 
medical malpractice case). 
In Holley, an expert witness presented raw data, much 
like the Fall Evidence, showing the frequency of perforations 
during colonoscopies and polypectomies.  This testimony was 
admitted over objection despite the fact “the statistics 
contained no breakdown between those cases involving 
perforations caused by negligence and those that did not.”  
270 Va. at 184, 613 S.E.2d at 427. Counsel's closing argument 
referred to the risks in the context of the standard of care.  
We held the argument using statistical evidence “was based 
upon a premise unsupported by the evidence: That perforations 
are just as likely to occur in the absence of negligence as in 
its presence.”  Id. at 185, 613 S.E.2d at 428. 
The Fall Evidence in the case at bar serves the same 
inappropriate purpose as the statistical evidence in Holley 
and the evidence of prior acts in Stottlemyer.   The Fall 
Evidence is based on a similar unsupported premise as the 
 
33
statistical evidence in Holley since falls are just as likely 
to result from another cause as from negligence.  As such, the 
Fall Evidence “is not probative of any issue” and “should not 
be admitted.”  Holley, 270 Va. at 185, 613 S.E.2d at 428.  
Although also offered at trial as evidence of notice for the 
Estate’s claim for punitive damages, the Fall Evidence could 
remain in the minds of the jurors long after the Estate 
nonsuited the punitive damages claim.  Such evidence could 
reasonably be expected to have “excited prejudice and misled 
the jurors.”  Stottlemyer, 268 Va. at 12, 597 S.E.2d at 194. 
The trial court’s erroneous admission of the Fall 
Evidence as to the issue of negligence cannot be deemed 
harmless error.  In determining the standard for harmless 
error, we are guided by Virginia's harmless-error statute, 
Code § 8.01-678.2  When reviewing whether an error is harmless, 
we “must decide whether the alleged error substantially 
influenced the jury.  If it did not, the error is harmless.”  
Clay v. Commonwealth, 262 Va. 253, 259, 546 S.E.2d 728, 731 
                     
2 Code § 8.01-678 applies in both the civil and criminal 
context and states, in relevant part: 
When it plainly appears from the record and the 
evidence given at the trial that the parties have 
had a fair trial on the merits and substantial 
justice has been reached, no judgment shall be 
arrested or reversed . . . [f]or any . . . defect, 
imperfection, or omission in the record, or for any 
error committed on the trial. 
 
 
34
(2001).  In Clay, we adopted the United States Supreme Court’s 
test for nonconstitutional harmless error, as articulated in 
Kotteakos v. United States, 328 U.S. 750 (1946): 
If, when all is said and done, the conviction is 
sure that the error did not influence the jury, or 
had but slight effect, the verdict and the judgment 
should stand . . . . But if one cannot say, with 
fair assurance, after pondering all that happened 
without stripping the erroneous action from the 
whole, that the judgment was not substantially 
swayed by the error, it is impossible to conclude 
that substantial rights were not affected. . . . If 
so, or if one is left in grave doubt, the conviction 
cannot stand. 
 
Clay, 262 Va. at 259-60, 546 S.E.2d at 731-32 (quoting 
Kotteakos, 328 U.S. at 764-65).  Applying the harmless error 
test and Code § 8.01-678, I cannot say that the admission of 
the Fall Evidence did not influence the jury, particularly in 
view of our existing precedent on similar statistical 
evidence.  Therefore, the error was not harmless. 
A cautionary instruction would likewise have been 
insufficient under the circumstances.  The most common 
purposes of cautionary instructions are to cure improper 
remarks or comments made in the jury’s presence, see Lewis v. 
Commonwealth, 269 Va. 209, 214, 608 S.E.2d 907, 910 (2005), or 
to caution the jury when questions by counsel are 
inappropriate.  See Lowe v. Cunningham, 268 Va. 268, 273, 601 
S.E.2d 628, 631 (2004).  When considering the prejudicial 
nature of a statement or question offered before a jury, we 
 
35
examine the relevance and content of the improper reference, 
whether the reference was deliberate or inadvertent in nature, 
and the probable effect of the improper reference.  Id. 
Assuming, arguendo, that a cautionary instruction had 
been offered in the case at bar, I believe that the impact of 
the Fall Evidence would have made an overwhelming, improper 
influence on the outcome of the case for the reasons recited 
above.  We have held, in the civil context, that “a court is 
required to grant a new trial, if requested, when the 
prejudicial effect of an improper remark or question is 
overwhelming, such that it cannot be cured by a cautionary 
instruction.”  Id.  Particularly in view of our precedent on 
the use of statistical evidence like the Fall Evidence, its 
impact could not be overcome by a cautionary instruction. 
 
In my view, the Defendants properly preserved their 
objection to the admission of Fall Evidence and were under no 
requirement to make another objection after the Estate 
nonsuited the punitive damages claim.  For the reasons stated 
above, I conclude the trial court erred in denying the 
Defendants’ objections and admitting the Fall Evidence.  This 
error was not harmless, could not have been cured by a 
cautionary instruction and requires reversal of the judgment 
of the trial court.  Therefore, I respectfully dissent from 
 
36
Part I.B. of the majority opinion and would reverse the 
judgment of the trial court and remand for a new trial. 
 
37