Case Title: Brugaletta v. Garcia

Citation: 

Docket Number: a-66-16

State: new-jersey

Court: New Jersey Supreme Court

Date: 2018-07-25T00:00:00Z

Document:
SYLLABUS

This syllabus is not part of the opinion of the Court. It has been prepared by the Office of the
Clerk for the convenience of the reader. It has been neither reviewed nor approved by the
Court. In the interest of brevity, portions of an opinion may not have been summarized.)

               Janell Brugaletta v. Calixto Garcia, D.O. (A-66-16) (079056)

Argued March 12, 2018 -- Decided July 25, 2018

LaVECCHIA, J., writing for the Court.

        This appeal arises from a discovery dispute in a medical malpractice action involving
a hospital’s and its staff’s care of a patient. The parties clash over the boundaries of
privileged material under the Patient Safety Act (PSA), 
N.J.S.A. 26:2H-12.23 to -12.25c, and
plaintiff’s ability to receive responsive discovery in order to prepare her action.

        Plaintiff Janell Brugaletta went to the emergency room of defendant Chilton
Memorial Hospital (CMH). She was admitted and underwent multiple surgical
interventions. During the period of those repeated procedures, plaintiff’s doctor recorded
that plaintiff missed doses of an antibiotic that the doctor had ordered. Plaintiff does not
appear to have been informed of that fact prior to the filing of the Appellate Division’s
opinion in this matter, although it is in plaintiff’s medical record turned over in discovery.

        Plaintiff filed a complaint alleging deviations from standards of medical care in
defendants’ diagnosis, care, and treatment of her. During pre-trial discovery, plaintiff served
a set of interrogatories on defendant CMH. The fifth interrogatory requested the names and
addresses of anyone who made or was aware of “a statement regarding this lawsuit,” as well
as access to, or a summary of, the statement, unless subject to a claim of privilege. CMH
objected to the question as overly broad and asserted that information sought by the request
was privileged. Plaintiff asked for a more specific answer, and CMH expanded as follows:
“Without waiving said objections, and without limitation, there are 2 Reports regarding this
matter. The reports are not included herein based upon the above objections. Additionally,
the information contained in said reports is protected by the privilege of self-critical
analysis,” as well as both the PSA and other legislation and hospital policy. Plaintiff made a
motion to compel discovery of the identities of the CMH committee or committees that
reviewed plaintiff’s case; submission of the related unredacted reports for in camera review;
and disclosure of redacted versions to plaintiff. CMH moved for a protective order.

        The trial court heard argument on the motions and conducted an in camera review of
the incident reports during which the court heard ex parte argument from defendants’
counsel. During the ex parte argument, the court marked the reports for identification as
DCP-1 and DCP-2, respectively. The trial court filed a written opinion ordering the release
of a redacted version of DCP-2. The court found that the report was the product of a self-
critical analysis conducted pursuant to the PSA and reviewed its content. The court found,
                                              1
contrary to CMH’s determination, that the report revealed plaintiff had suffered a Serious
Preventable Adverse Event (SPAE) under the PSA. The court then considered two
interrelated issues: (1) “when a hospital erroneously fails to report a [SPAE], what[,] if
anything, should be the remedy?”; and (2) “what standard [of review] should be applied?”
The court ordered the release of DCP-2 but prepared a redacted version of the document in
an attempt to honor the self-critical-analysis privilege while revealing the facts of the SPAE
to plaintiff. Further, the court ordered CMH to report the SPAE to the DOH.

        The Appellate Division reversed the trial court’s order. 
448 N.J. Super. 404, 408, 419
(App. Div. 2017). The appellate panel first determined that the only precondition to the
applicability of the PSA’s self-critical-analysis privilege is whether the hospital performed
the self-critical analysis in compliance with 
N.J.S.A. 26:2H-12.25(b) and its implementing
regulations. Id. at 414-15. The panel considered whether the trial court properly found that a
SPAE had occurred, and it determined that the trial court’s SPAE determination was in error
because “an expert opinion was essential” in order to demonstrate that plaintiff’s assumed
serious adverse event occurred because of an error in her care. Id. at 418-19.

       The Court granted plaintiff’s motion for leave to appeal. ___ N.J. ___ (2017).

HELD: The Court affirms the panel’s order shielding the redacted document from discovery
because the PSA’s self-critical-analysis privilege prevents its disclosure. The Court also
affirms the panel’s determination that, when reviewing a discovery dispute such as this, a trial
court should not be determining whether a reportable event under the PSA has occurred. The
Court reverses the judgment to the extent it ends defendants’ discovery obligation with respect
to this dispute, finding that defendants have an unmet discovery duty under Rule 4:17-4(d) that
must be addressed. Accordingly, the Court provides direction on how the court should have
addressed, through New Jersey’s current discovery rules, the proper balancing of interests
between the requesting party and the responding party here, and remands to the trial court.

1. The PSA was legislatively designed to minimize adverse events caused by patient-safety
system failures in a hospital or other health care facility. Through that multi-faceted
statutory scheme, the Legislature sought to encourage self-critical analysis related to adverse
events and near misses by fostering a non-punitive, confidential environment in which health
care facilities can review internal practices and policies and report problems without fear of
recrimination while simultaneously being held accountable. The PSA requires health care
facilities to formulate processes wherein patient safety committees comprised of members
with “appropriate competencies” can perform self-critical analyses on SPAEs and near-miss
incidents, formulate evidence-based plans for increasing patient safety, and provide for on-
going personnel training related to patient safety. 
N.J.S.A. 26:2H-12.25(b); N.J.A.C. 8:43E-
10.4 and -10.5(a). When a health care facility or an employee thereof suspects that a SPAE
may have occurred, the facility’s patient safety committee must have in place a process for
employees to alert the committee to that fact. N.J.A.C. 8:43E-10.5(a)(1). Then the patient
safety committee must do two things: (1) perform a “root cause analysis” to identify the
causes of a SPAE and appropriate corrective action, N.J.A.C. 8:43E-10.3 and -10.4(d)(7);
and (2) report the SPAE to the DOH and to the affected patient. Notably, the PSA confers a
                                                2
privilege on a facility’s self-critical analysis and the reporting of a SPAE to the DOH.

N.J.S.A. 26:2H-12.25(f)(1), -12.25(g)(1); N.J.A.C. 8:43E-10.9(a)(1). Regulations
promulgated to clarify the PSA’s self-critical-analysis privilege specify that the documents,
materials, or information must have been developed “exclusively during the process of self-
critical analysis.” N.J.A.C. 8:43E-10.9(b). (pp. 18-22)

2. In C.A. ex rel. Applegrad v. Bentolila, the Court dismissed, in dicta, an argument that a
finding that an event is not reportable should abrogate the self-critical-analysis privilege.

219 N.J. 449, 471 n.14 (2014). (p. 23)

3. Importantly, the privileges provided in the PSA do not bar the discovery or admission into
evidence of information that would otherwise be discoverable or admissible. Relatedly, the
PSA provides that its provisions do not change the discoverability of information or
documents obtained from other sources, or in other contexts. (pp. 23-24)

4. The trial court was well within proper judicial bounds when examining the facts
underlying the claim of privilege in this case. When a requesting party demands information
or documents over which the opposing party claims a privilege, the responding party may
withhold that information or document as long as it expressly asserts the claimed privilege
and details the nature of the information withheld. When a requesting party challenges an
assertion of privilege, the court must undertake an in camera review of the purportedly
privileged document or information and make specific rulings as to the applicability of the
claimed privilege. However, the court exceeded its authority, first in declaring that a SPAE
had occurred and then in issuing its related orders that CMH disclose to plaintiff a redacted
version of DCP-2 and report the event to the DOH. The Legislature inserted no role for a
trial court to play in reviewing the SPAE determination made by a patient safety committee
of a health care facility. The Court declines to entangle the courts in an essentially
administrative function, and accordingly expresses no opinion on what standard should
govern the determination of whether a SPAE occurred or the related issues of causation and
expert testimony. To the extent that the Appellate Division refined the review standard for
identifying a SPAE, the Appellate Division’s analysis is vacated. (pp. 24-27)

5. The language and structure of the PSA leave no reasonable doubt about the legislative
intent regarding the self-critical-analysis privilege. As the Appellate Division properly held,
the only precondition to application of the PSA’s privilege is whether the hospital performed
its self-critical analysis in procedural compliance with 
N.J.S.A. 26:2H-12.25(b) and its
implementing regulations. 
448 N.J. Super. at 414-15. To construe the statute otherwise -- by
making its protective privilege dependent on a SPAE finding -- would be at cross-purposes
with the patent legislative desire to encourage trust and reporting by health care facilities
whenever a concern about a near miss or adverse event comes to light. Accordingly, as
intimated through dictum in C.A., the finding that an event is not reportable does not
abrogate the self-critical-analysis privilege. The PSA was misapplied and the trial court’s
discretion abused when it declared that a SPAE occurred and ordered CMH to release a
redacted form of DCP-2 to plaintiff and report the event to the DOH. A court may not order
the release of documents prepared during the process of self-critical analysis. (pp. 27-30)
                                                 3
6. Although a court may not order release in discovery of a report developed during self-
critical analysis, even if redacted, and although a court may not determine whether it agrees
with the health care facility’s conclusion as to whether an adverse event constitutes a SPAE
and, based on that determination, order disclosure to the DOH, the court’s role in resolving
this discovery dispute is far from over. (pp. 30-32)

7. The PSA did not abrogate existing health care law and does not immunize from discovery
information otherwise discoverable. The record in this case discloses that among the patient
records, there are notations across several pages that, when read together, reveal the nature of
the events underlying the divergent SPAE determinations of the committee and the trial
court. Those notations are in plaintiff’s medical records pursuant to health care law
requirements concerning patient recordkeeping. Defendants provided the court a concise
step-by-step narrative, walking the court through the relevant excerpts of plaintiff’s patient
records, to demonstrate that defendants had provided the underlying non-privileged facts
about plaintiff’s care that sufficiently addressed the information requested in interrogatory
five and that could be disclosed without piercing the PSA privilege. Instead, the trial court
should have ordered defendants to provide plaintiff a narrative similar in form to the one they
presented the court. That remedy would have allowed the court to balance the litigation
interests of the parties, to avoid transgressing the privilege and the salutary purposes it is
intended to achieve, and to keep the courts out of a regulatory scheme. (pp. 32-36)

8. New Jersey trial courts have the authority under Rule 4:17-4(d) to compel a party
producing documentary records to provide, with the records, a narrative that specifies where
responsive information may be found. Plaintiff was entitled to be informed of an adverse
incident related to her care in defendants’ response to discovery demands because such an
incident was memorialized through various entries in her patient records. Yet, she was not
informed of it and, notwithstanding her fifth interrogatory, received no specification or
narrative to accompany the approximately 4500 pages of medical records that would lead her
to the discrete yet interconnected notations of the incident that appear on nine pages of that
record. The trial court should, on remand, order a narrative to accompany the documents
already turned over to plaintiff in order to satisfy defendants’ obligation to provide a
complete response to interrogatory number five. (pp. 36-43)

       AFFIRMED IN PART, REVERSED IN PART.

        JUSTICE ALBIN, dissenting, would make clear that the patient had a right to be
told about the lapse in her treatment at the time it occurred and in a way that she reasonably
could have understood under the Patient Bill of Rights, even if it had not been entered in her
patient records as required by N.J.A.C. 8:43G-15.2(e), and even if she had not demanded the
information in a medical malpractice lawsuit. In Justice Albin’s view, the majority’s
interpretation of the PSA erodes significant rights the Legislature conferred on patients.

CHIEF JUSTICE RABNER and JUSTICES PATTERSON, FERNANDEZ-VINA,
SOLOMON, and TIMPONE join in JUSTICE LaVECCHIA’s opinion. JUSTICE
ALBIN filed a dissenting opinion.
                                  4
                                     SUPREME COURT OF NEW JERSEY
                                       A-
66 September Term 2016
                                                079056

JANELL BRUGALETTA,

    Plaintiff-Appellant,

         v.

CALIXTO GARCIA, D.O., STEVEN
D. RICHMAN, M.D. and PATRICK
J. HINES, M.D.,

    Defendants,

         and

CHILTON MEMORIAL HOSPITAL,

    Defendant-Respondent.

         Argued March 12, 2018 – Decided July 25, 2018

         On appeal from the Superior Court, Appellate
         Division, whose opinion is reported at 448
         N.J. Super. 404 (App. Div. 2017).

         Ernest P. Fronzuto argued the cause for
         appellant (Fronzuto Law Group, attorneys;
         Ernest P. Fronzuto, of counsel and on the
         brief, and Casey Anne Cordes, on the brief).

         Anthony Cocca argued the cause for
         respondent Chilton Medical Center (Bubb,
         Grogan & Cocca, attorneys; Anthony Cocca, of
         counsel and on the brief).

         E. Drew Britcher argued the cause for amicus
         curiae New Jersey Association for Justice
         (Britcher Leone, attorneys; E. Drew
         Britcher, of counsel and on the brief, and
         Jessica E. Choper, on the brief).

         Ross A. Lewin argued the cause for amicus
         curiae New Jersey Hospital Association

                               1
         (Drinker Biddle & Reath, attorneys; Ross A.
         Lewin, of counsel and on the brief).
         Philip S. Goldberg submitted a brief on
         behalf of amici curiae American Medical
         Association and Medical Society of New
         Jersey (Shook, Hardy & Bacon, attorneys).

    JUSTICE LaVECCHIA delivered the opinion of the Court.

    This appeal arises from a discovery dispute in a medical

malpractice action involving a hospital’s and its staff’s care

of a patient.   The parties clash over the boundaries of

privileged material under the Patient Safety Act (PSA), 
N.J.S.A.

26:2H-12.23 to -12.25c, and plaintiff’s ability to receive

responsive discovery in order to prepare her action.

    In enacting the PSA, the Legislature sought to reduce

medical errors by promoting internal self-reporting and

evaluation by health care facilities.   The Legislature protected

and encouraged this new system of self-critical analysis through

a statutory privilege, designed to shore up the trust expected

and needed from health care facilities for the success of its

facility-initiated program.   At the same time, the Legislature

expressly left untouched a plaintiff’s ability to secure

discovery of underlying information available through other

means.

    In this matter, the trial court endeavored to balance the

interests of the parties using the framework of the PSA and

ordered the release of a redacted document prepared internally

                                 2
by hospital personnel during the process of self-critical

analysis.   On appeal, defendants claimed that the trial court

impermissibly involved itself in a PSA regulatory function and,

further, that release of the redacted document would result in a

breach of the statutory privilege.    The Appellate Division

reversed the trial court’s order of release.    We now affirm in

part and reverse in part the Appellate Division judgment, and we

remand for proceedings in accordance with this opinion.

    We affirm the panel’s order shielding the redacted document

from discovery because the PSA’s self-critical-analysis

privilege prevents its disclosure.    We also affirm the panel’s

determination that, when reviewing a discovery dispute such as

this, a trial court should not be determining whether a

reportable event under the PSA has occurred.

    However, importantly, we reverse the judgment to the extent

it ends defendants’ discovery obligation with respect to this

dispute.    We find that defendants have an unmet discovery duty

under Rule 4:17-4(d) that must be addressed.    Accordingly, we

provide direction on how the court should have addressed,

through our current discovery rules, the proper balancing of

interests between the requesting party and the responding party

here, and we remand to the trial court for entry of an order

consistent with the guidance set forth in this opinion and for

such further proceedings as are necessary.

                                  3
                                I.

     Because this matter involves a confidential record and

comes before us on interlocutory appeal from the trial court’s

disposition of the discovery dispute, we present only a brief

recitation of the facts and procedural history.

                                A.

     On January 12, 2013, plaintiff Janell Brugaletta1 went to

the emergency room of defendant Chilton Memorial Hospital (CMH)

complaining of a week-long fever accompanied by abdominal and

body pains.   She was examined by defendant Calixto Garcia, D.O.,

diagnosed with pneumonia, and admitted to the hospital.   A

Computed Tomography (CT) scan revealed a pelvic abscess due to a

perforated appendix.   Plaintiff’s doctors drained the abscess

and plaintiff’s fever abated.   Although the abdominal pain

lessened, plaintiff experienced worsening pain in her legs.

     Additional CT scans led CMH doctors to determine that

plaintiff appeared to be developing a necrotizing fasciitis2 in

1  Although some record documents spell plaintiff’s name as
“Janelle,” we herein adopt the spelling used in the documents
submitted on plaintiff’s behalf.
2  “Necrotizing fasciitis is a bacterial infection of the tissue
under the skin that surrounds muscles, nerves, fat, and blood
vessels. . . . Once in the body, the bacteria spread quickly
and destroy the tissue they infect.” Ctrs. for Disease Control
& Prevention, Acting Fast is Key with Necrotizing Fasciitis,
https://www.cdc.gov/features/necrotizingfasciitis/index.html
(last updated July 9, 2018).
                                 4
her thigh muscles and right buttock due to the abscess drainage

leaking around a nerve.   Plaintiff obtained a second opinion,

and, thereafter, an orthopedic surgeon performed a fasciotomy

and debridement.   After those procedures, plaintiff was placed

in the intensive care unit.   Plaintiff then underwent further

surgical interventions, including additional procedures to

debride the fasciitis and close the wound left by the abscess,

as well as an appendectomy.

    On January 30, 2013, during the period in which plaintiff

was undergoing repeated procedures, plaintiff’s doctor recorded

that plaintiff missed doses of an antibiotic that the doctor had

ordered.   Plaintiff does not appear to have been informed of

that fact prior to the filing of the Appellate Division’s

published opinion in this matter, although it is in plaintiff’s

medical record turned over in discovery.

    By the time of her February 13, 2013 discharge -- three

weeks after appearing in the CMH emergency room -- plaintiff’s

abscess drains were removed and the abdominal pain was resolved.

Nevertheless, plaintiff reports having left the hospital

experiencing residual pain and permanent injuries to her legs

and buttock.

    On January 13, 2015, plaintiff filed a complaint naming Dr.

Garcia and CMH as defendants, alleging deviations from standards

of medical care in their diagnosis, care, and treatment of her.

                                 5
About a year later, plaintiff filed an amended complaint to add

claims against Steven D. Richman, M.D., Patrick J. Hines, M.D.,

and Montclair Radiology, alleging that Doctors Richman and

Hines, who performed her CT scans and CT-guided drainage,

negligently failed to detect a second abscess.

    During pre-trial discovery, plaintiff served a set of

interrogatories on defendant CMH on March 5, 2015.     The fifth

interrogatory requested the following:

         State:

              (a)   the name and address of any person
                    who has made a statement regarding
                    this lawsuit;

              (b)   whether the statement was oral or in
                    writing;

              (c)   the date the statement was made;

              (d)   the name and address of the person
                    to whom the statement was made;

              (e)   the name and address of each person
                    present when the statement was made;
                    and

              (f)   the name and address of each person
                    who has knowledge of the statement.

         Unless subject to a claim of privilege, which
         must be specified:

              (a)   attach a copy of the statement, if
                    it is in writing;

              (b)   if the statement was oral, state
                    whether a recording was made and, if
                    so, set forth the nature of the
                    recording and the name and address

                                6
                    of the person who has custody of it;
                    and

              (c)   if the statement was oral and no
                    recording was made, provide a
                    detailed summary of its contents.

On June 1, 2015, defendant CMH responded:

              Upon the advice of counsel, objection to
         the form of the question.     This request is
         overly broad, burdensome and intended to
         harass this defendant and seeks information
         that is not reasonably calculated to lead to
         the discovery of admissible evidence pursuant
         to R. 4:10-2 and is otherwise irrelevant under
         N.J.R.E. 401.    Further, this request seeks
         information that is protected by the work-
         product doctrine, the peer review privilege,
         the privilege of self-critical analysis, the
         attorney client privilege and is otherwise
         evidence of subsequent remedial measures under
         N.J.R.E.   407.       Without   waiving   said
         objections, to be provided.

    Following plaintiff’s request for a more specific answer to

interrogatory number five, CMH served plaintiff with further

detail regarding the claimed privilege.     The expanded answer

repeated the above response verbatim until the final sentence,

upon which it elaborated as follows:

              Without waiving said objections, and
         without limitation, there are 2 Reports
         regarding this matter.    The reports are not
         included   herein   based   upon   the  above
         objections.    Additionally, the information
         contained in said reports is protected by the
         privilege of self-critical analysis and the
         Peer [R]eview and Improvement Act of 1982[,]
         42 U.S.C. § 1320c-3 et seq., the Health Care
         Quality Improvement Act[,] 42 U.S.C. § 11101,
         et seq. 
N.J.S.A. 2A:84A-22.8, [the PSA,] and
         Hospital Policy.     The documents and the

                                7
          information contained therein are strictly
          confidential and may not be disclosed or
          distributed to any person or entity outside
          the peer review or utilization review process,
          except as otherwise provided by law.

                Enclosed is a Privilege Log of Incident
          Reports. Please note, there exists a letter
          dated    February   20,   2013  from   Charlene
          McCallum,      Patient    Representative,    to
          [plaintiff], bates stamped Confidential --
          Incident    Report    005,   which   is   being
          disclosed. [3]  However, the 2 Incident Reports
          referenced above, are not being produced based
          on the aforementioned objections.

     On September 22, 2015, plaintiff made a motion to compel

discovery of the identities of the CMH committee or committees

that reviewed plaintiff’s case; submission of the related

unredacted reports for in camera review; and, ultimately,

disclosure of redacted versions to plaintiff.   CMH filed a

cross-motion for a protective order.   Accompanying CMH’s motion

was the certification of Ebube Bakosi, M.D., stating that two

incident reports prepared “for the sole purpose of complying

with the requirements of the PSA” were generated regarding

plaintiff and that those reports were forwarded to the Patient

Safety Committee but no other committees.

     The trial court heard argument on the motions and conducted

an in camera review of the incident reports during which the

3  The report, designated Incident Report 005, appears related to
a complaint plaintiff had regarding the CMH staff and is not a
subject of this appeal.

                                8
court heard ex parte argument from defendants’ counsel.     During

the ex parte argument, the court marked the reports for

identification as DCP-1 and DCP-2, respectively.4

      On March 29, 2016, the trial court filed a written opinion

ordering the release of a redacted version of DCP-2.     The court

found that the report was the product of a self-critical

analysis conducted pursuant to the PSA and reviewed its content.

The court found, contrary to CMH’s determination, that the

report revealed plaintiff had suffered a Serious Preventable

Adverse Event (SPAE) under the PSA.5   The court then considered

two interrelated issues:   (1) “when a hospital erroneously fails

to report a [SPAE], what[,] if anything, should be the remedy?”;

and (2) “what standard [of review] should be applied?”     The

court first rejected as “unjust and incorrect” a reading of the

statute that would “automatically negate the entire privilege

whenever a failure to report occurs” after considering

“instances where a hospital’s Patient Safety Committee [formed

and operating pursuant to the PSA and its implementing

regulations] makes a good faith finding that there was not a

4   DCP-1 is not a subject of this appeal.
5  We will return to the definition of and requirements attendant
upon SPAEs later in the opinion. For now, it suffices to note
that health care facilities have certain reporting obligations
with respect to SPAEs under the PSA. We focus here on the trial
court’s conclusions based on its determination that plaintiff
suffered a SPAE that the CMH failed to report.
                                 9
[SPAE], only to have a [c]ourt disagree.”    The court noted that

“[s]uch an outcome would not comport with the inherent

discretion that Patient Safety Committees have in determining

whether a [SPAE] occurred.”

    Instead, to respect the inherent discretion vested in

Patient Safety Committees for making SPAE determinations, as

well as the policy goals of the PSA, the court determined that

         [i]f a reviewing [c]ourt concludes that a
         [SPAE] occurred and was not reported, the
         Hospital must be ordered to report the event
         to the Patient and to the New Jersey
         Department of Health [(DOH)] as mandated by
         the [PSA]; [and] [i]f the [c]ourt further
         concludes that the Hospital’s decision not to
         report was “arbitrary and capricious,” the
         hospital loses its privileges under the [PSA].

    Although the court found a “clear error in judgment” in

CMH’s finding that no SPAE occurred here, it determined that the

error did not rise to the level of being an arbitrary and

capricious act.    Thus, although the court ordered the release of

DCP-2, the court prepared a redacted version of the document in

an attempt to honor the self-critical-analysis privilege while

revealing the facts of the SPAE to plaintiff.    Further, the

court ordered CMH to report the SPAE to the DOH.

    The court stayed its order to permit defendants to file for

leave to appeal.

                                 B.

                                 10
      The Appellate Division granted plaintiff leave to appeal

and reversed the trial court’s order.    Brugaletta v. Garcia, 
448 N.J. Super. 404, 408, 419 (App. Div. 2017).    Framing the issue

as a review of a discovery disposition, id. at 411, the

appellate panel first determined that the only precondition to

the applicability of the PSA’s self-critical-analysis privilege

is whether the hospital performed the self-critical analysis in

compliance with 
N.J.S.A. 26:2H-12.25(b) and its implementing

regulations, id. at 414-15.    According to the panel, the plain

language of 
N.J.S.A. 26:2H-12.25(g), which establishes the self-

critical-analysis privilege, does not condition the privilege on

a SPAE finding or compliance with the PSA’s reporting

requirements.    Id. at 416-17.

      The panel also reviewed the trial court’s decision to order

that CMH report the SPAE to plaintiff and the DOH.    Id. at 417-

19.   In so doing, the panel considered whether the trial court

properly found that a SPAE had occurred, and it determined that

the trial court’s SPAE determination was in error.    Id. at 418-

19.   In order to determine whether the record contained

sufficient evidence to support the trial court’s SPAE

determination, the panel looked to the definitions of the three

elements of a SPAE.    Id. at 418 (citing 
N.J.S.A. 26:2H-12.25(a);

N.J.A.C. 8:43E-10.3).    The panel said that a proper finding of a

SPAE requires:    (1) an adverse event, or “a negative consequence

                                  11
of care that results in unintended injury or illness”; (2) a

serious event, or one that results in “death or loss of a body

part, or disability or loss of bodily function lasting more than

seven days or still present at the time of discharge”; and (3) a

preventable event, meaning one that “could have been anticipated

and prepared against, but occurs because of an error or other

system failure.”     Id. at 413 (quoting 
N.J.S.A. 26:2H-12.25(a)

and later citing N.J.A.C. 8:43E-10.3).

    The panel assumed for the sake of analysis that an adverse,

serious event took place.    Id. at 418-19.    However, the panel

stated that the third PSA requirement -- a preventable event --

is a causation element, namely that “the event must occur

because of the error or system failure.”      Id. at 418 (internal

quotation marks omitted).    Relying on Kelly v. Berlin, 
300 N.J.

Super. 256, 268 (App. Div. 1997), the panel concluded that “an

expert opinion was essential” in order to demonstrate that

plaintiff’s assumed serious adverse event occurred because of an

error in her care.    Id. at 419.    Because “the trial court [did]

not rely on an expert opinion to conclude that Brugaletta’s

serious adverse event occurred because of” an error in her care,

the panel declared the trial court’s SPAE finding to be

unsupported by the record.    Ibid. (internal quotation marks

omitted).

                                    C.

                                    12
    We granted plaintiff’s motion for leave to appeal pursuant

to Rule 2:2-2(b).     ___ N.J. ___ (2017).    We also granted amicus

curiae status to the New Jersey Association for Justice (NJAJ),

the American Medical Association and Medical Society of New

Jersey (collectively, AMA), and the New Jersey Hospital

Association (NJHA).

                                 II.

                                  A.

    Plaintiff maintains that the PSA’s procedural requirements

for investigating whether a SPAE occurred and the requirements

to disclose a SPAE are distinct.       According to plaintiff, the

disclosure requirements rely on a hospital’s subjective

determination as to whether a SPAE has occurred.      Plaintiff

asserts that, because the PSA conferred on patients the right to

know about SPAEs that occur during their treatment or care,

judicial review of SPAE determinations must logically follow,

otherwise, the PSA could become a method of information

suppression by hospitals seeking to avoid disclosure of SPAEs.

Thus, plaintiff argues that judicial review is necessary to

enforce and protect the patient’s right to know, as well as to

avoid a patient suffering irreparable harm.      Plaintiff urges

adoption of the trial court’s standard because it balances “the

competing policy interests set forth in the PSA:      the hospital’s

                                  13
interests in confidential self-critical analysis and the goal of

system-wide reporting and patient notification” of SPAEs.

    Plaintiff maintains that the Appellate Division’s

contrasting approach places an insurmountable burden on

plaintiffs seeking to enforce their right to know under the PSA

by requiring a court to rely on an expert opinion on causation

when, in fact, the relevant regulations create a presumption of

causation.   Moreover, plaintiff contends that it is more

practical to place the burden on the hospital to disprove

causation.   That is because (1) plaintiffs are not likely to

know the factual circumstances underlying a SPAE because the

records are unobtainable; and (2) it is the hospital asserting

the privilege and, therefore, the hospital should bear the cost

and burden of disproving causation.

                                B.

    Defendants argue that the right to know, which plaintiff

insists was created in the PSA, does not exist and, to the

extent that it does, it is not the primary focus of the statute

or its implementing regulations.

    According to defendants, the PSA was enacted to foster

confidential reporting of self-critical analyses in order to

make patient environments safer.     In that vein, defendants note

that the PSA mandates that hospitals must meet several

obligations, including creation of a patient safety committee,

                                14
compliance with investigative procedures, and reporting to the

DOH and SPAE-affected patients.    To incentivize compliance, the

PSA also created an absolute privilege for material produced

pursuant to the PSA’s procedural requirements and within the

scope of the statute, which privilege is not reliant on whether

a hospital correctly determines that a SPAE has occurred or on a

patient’s need for information.    Defendants point to the

statute’s language to argue that the Legislature did not provide

for judicial review of SPAE determinations and that the self-

critical-analysis privilege does not rely on whether a hospital

fails to find a SPAE and report it to the DOH and the patient.

Defendants assert that such review is inconsistent with the

statute’s express goals.

    Further, defendants claim that plaintiff misstates the

panel’s holding in asserting that the Appellate Division placed

an insurmountable burden on her by requiring an expert opinion

to demonstrate causation.   Rather, according to defendants, the

panel merely held that the record did not support a finding of a

SPAE and rejected plaintiff’s argument that the PSA’s

implementing regulations created a presumption of causation.

    Finally, defendants emphasize that the information

underlying what the trial court found to be a SPAE is already

available to plaintiff:    defendants have turned over non-

privileged discovery in the form of plaintiff’s hospital chart,

                                  15
which contains the factual material underlying what the trial

court determined was a SPAE.

                                C.

    Supporting plaintiff, amicus NJAJ argues that a hospital

should not be permitted to use its compliance with the PSA’s

procedural requirements as a means to circumvent the PSA’s

disclosure requirement.   According to the NJAJ, the PSA did not

abrogate preexisting law:   like prior law, the PSA does not

cloak facts related to a patient’s treatment in privilege merely

because they were discovered pursuant to a mandatory

investigation.   Further, the NJAJ asserts that the Appellate

Division erred by failing to analyze CMH’s claim of privilege

consistent with Christy v. Salem, 
366 N.J. Super. 535 (App. Div.

2004).   The NJAJ argues that Christy requires a court to

“balance a 'plaintiff’s right to discover information concerning

his care and treatment’ . . . against the 'public interest to

improve the quality of care and help to ensure that

inappropriate procedures . . . are not used on future patients’”

when a privilege is claimed.   (quoting 
366 N.J. Super. at 541).

Finally, the NJAJ urges this Court to allow courts to perform in

camera reviews of hospitals’ SPAE determinations and, if the

reviewing court finds that a SPAE occurred, to permit that court

to release any factual matter relating to the SPAE to the

plaintiff and report the SPAE to the DOH.

                                16
                                D.

    Supporting defendants’ position, amici AMA and NJHA argue

against a judicially crafted exception to the self-critical-

analysis privilege that relies on a court’s review of a SPAE

determination or a hospital’s compliance with the PSA’s

reporting requirements.   According to those amici, the self-

critical-analysis privilege is contingent only on compliance

with the PSA’s procedural requirements, which, if met, shield

the analysis and its resulting reports.

    The NJHA emphasizes that the court’s role in reviewing PSA-

related issues is limited to ruling on discovery challenges and

that the PSA does not provide for judicial review of a

hospital’s overall compliance with the statute.    That role,

according to the NJHA, is filled by the DOH.     Further, the NJHA

argues requiring a hospital to turn over all of the factual

materials underlying a SPAE, as well as the fact that a SPAE

occurred, would result in providing patients with more

information than the PSA requires.     The NJHA points to PSA

language that a hospital need advise a patient only that a SPAE

has, or likely has, occurred.

                                III.

    We turn first to the claim that the trial court erred as a

matter of law, misconstruing its role when interacting with the

PSA process and the scope of the self-critical-analysis

                                17
privilege.   Generally, we accord substantial deference to a

trial court’s disposition of a discovery dispute.     See Capital

Health Sys., Inc. v. Horizon Healthcare Servs., Inc., 
230 N.J.
 73, 79-80 (2017).    We will not ordinarily reverse a trial

court’s disposition of a discovery dispute “absent an abuse of

discretion or a judge’s misunderstanding or misapplication of

the law.”    Ibid.   To the extent that our review involves

questions of statutory interpretation, however, our review is de

novo.   Verry v. Franklin Fire Dist. No. 1, 
230 N.J. 285, 294

(2017).

                                  A.

     The statute that created the self-critical-analysis

privilege is central in the parties’ arguments.     The PSA was

already examined in C.A. ex rel. Applegrad v. Bentolila, 
219 N.J. 449 (2014), a case in which we had our first opportunity to

consider the applicability of the privilege and did so by

setting forth the basic structure of the statute.
6 For our

 6  In that discussion, we noted that although the PSA was enacted
in 2004, its implementing regulations were not effective until
March 2008, C.A., 
219 N.J. at 462, 467, which was roughly nine
months after the document at issue was prepared, id. at 455. We
concluded that the hospital in that matter should not be
penalized with disclosure of its deliberative material because
it did not adhere to strict rule requirements about internal
committee operation during self-critical analysis when those
rule requirements had not yet been made known. Id. at 473. The
present matter arose after the regulatory structure was in full
effect.
                                  18
present analysis, we summarize the core features of the PSA and

its implementing regulations.

    The PSA was legislatively designed to minimize adverse

events caused by patient-safety system failures in a hospital or

other health care facility.     
N.J.S.A. 26:2H-12.24(b) and (c).

As noted in C.A., through that multi-faceted statutory scheme,

the Legislature sought to encourage self-critical analysis

related to adverse events and near misses by fostering a non-

punitive, confidential environment in which health care

facilities can review internal practices and policies and report

problems without fear of recrimination while simultaneously

being held accountable.   
219 N.J. at 464; see also 
N.J.S.A.

26:2H-12.24(e).

    The PSA requires health care facilities to formulate

processes wherein patient safety committees comprised of members

with “appropriate competencies” can perform self-critical

analyses on SPAEs and near-miss incidents, formulate evidence-

based plans for increasing patient safety, and provide for on-

going personnel training related to patient safety.    
N.J.S.A.

26:2H-12.25(b); N.J.A.C. 8:43E-10.4 and -10.5(a).    Thus,

reported SPAEs receive intense review through the patient safety

committee’s process of self-critical analysis.    See N.J.A.C.

8:43E-10.4(b)(3).

                                  19
    The PSA and its implementing regulations define a SPAE as

“an adverse event that is a preventable event and results in

death or loss of a body part, or disability or loss of bodily

function lasting more than seven days or still present at the

time of discharge from a health care facility.”    
N.J.S.A. 26:2H-

12.25(a); N.J.A.C. 8:43E-10.3.    An adverse event is one “that is

a negative consequence of care that results in unintended injury

or illness, which may or may not have been preventable,” and a

preventable event is “an event that could have been anticipated

and prepared against, but occurs because of an error or other

system failure.”    
N.J.S.A. 26:2H-12.25(a); N.J.A.C. 8:43E-10.3.

    When a health care facility or an employee thereof suspects

that a SPAE may have occurred, the facility’s patient safety

committee, required by 
N.J.S.A. 26:2H-12.25(b) and N.J.A.C.

8:43E-10.4, must have in place a process for employees to alert

the committee to that fact.   N.J.A.C. 8:43E-10.5(a)(1).    Then

the patient safety committee must do two things:   (1) perform a

“root cause analysis” to identify the causes of a SPAE and

appropriate corrective action, N.J.A.C. 8:43E-10.3 and -

10.4(d)(7); and (2) report the SPAE to the DOH and to the

affected patient.

    Regarding the latter, the patient safety committee must

report all SPAEs to the DOH, 
N.J.S.A. 26:2H-12.25(c), within

five business days of the event’s discovery, N.J.A.C. 8:43E-

                                 20
10.6(b).   The report to the DOH must include, among other

things, how the event was discovered, the nature of the event,

and what corrective actions were taken.     N.J.A.C. 8:43E-10.6(c).

A failure to report a SPAE to the DOH can subject a facility to

civil monetary fines.    See N.J.A.C. 8:43E-3.4(a)(14).     The

health care facility also must alert the affected patient to the

SPAE, 
N.J.S.A. 26:2H-12.25(d); N.J.A.C. 8:43E-10.7(a)(1), and

generally must do so within twenty-four hours of the event’s

discovery, N.J.A.C. 8:43E-10.7(b).

    Notably, the PSA confers a privilege on a facility’s self-

critical analysis and the reporting of a SPAE to the DOH.         See

C.A., 
219 N.J. at 467.   The PSA bars discovery of “[a]ny

documents, materials, or information received by the [DOH]” in

the context of reporting a SPAE.      
N.J.S.A. 26:2H-12.25(f)(1);

N.J.A.C. 8:43E-10.9(a)(1).

    Similarly, regarding information developed as part of the

process of self-critical analysis, the PSA provides that

           [a]ny documents, materials, or information
           developed by a health care facility as part of
           a process of self-critical analysis conducted
           pursuant to subsection b. of this section
           [(codified    as   N.J.S.A.   26:2H-12.25(b))]
           concerning preventable events, near-misses
           and   adverse    events,   including   serious
           preventable adverse events, and any document
           or oral statement that constitutes the
           disclosure provided to a patient or the
           patient’s family member or guardian pursuant
           to subsection d. of this section [(codified as
           N.J.S.A. 26:2H-12.25(d))], shall not be:

                                 21
          subject to discovery or admissible as evidence
          or otherwise disclosed in any civil, criminal,
          or administrative action or proceeding.

          [N.J.S.A. 26:2H-12.25(g)(1).]

Regulations promulgated to clarify the PSA’s self-critical-

analysis privilege delineated in section 12.25(g) specify that

the documents, materials, or information must have been

developed “exclusively during the process of self-critical

analysis” performed pursuant to N.J.A.C. 8:43E-10.4, -10.5, or -

10.6.   N.J.A.C. 8:43E-10.9(b); accord C.A., 
219 N.J. at 467-68

(discussing exclusivity requirement of N.J.A.C. 8:43E-

10.9(b)(1)).   As stated in C.A.,

          pursuant to N.J.A.C. 8:43E-10.9, . . . the
          statutory privilege applies only to documents,
          materials     and    information     developed
          exclusively during self-critical analysis
          conducted during one of three specific
          processes: the operations of the patient or
          resident safety committee pursuant to N.J.A.C.
          8:43E-10.4, the components of a patient or
          resident safety plan as prescribed by N.J.A.C.
          8:43E-10.5, or reporting to regulators under
          N.J.A.C. 8:43E-10.6. In the regulations that
          became effective in 2008, the statutory
          standard was expanded upon in two significant
          respects:     first, to require that the
          documents, materials and information at issue
          be “exclusively” prepared in the setting of a
          qualifying self-critical analysis process,
          and second, to mandate that the self-critical
          analysis be conducted in accordance with one
          of three accompanying regulations as a
          prerequisite for the privilege to attach,
          N.J.A.C. 8:43E-10.4, -10.5 and -10.6.

          [
219 N.J. at 468 (citations omitted).]

                                22
    Although not presented in the facts of C.A., we dismissed,

in dicta, an argument that a finding that an event is not

reportable should abrogate the self-critical-analysis privilege.

Id. at 471 n.14.   We commented that nothing in the language of

the PSA “limits the privilege to settings in which the incident

[being investigated] is ultimately determined to be subject to

mandatory reporting” to the DOH, and, therefore, the self-

critical-analysis privilege “is not constrained to cases in

which the deliberative process concludes with a determination

that the case is reportable.”   Ibid.   We added the comment to

underscore our perception, at the time, that the goal of

fostering facilities’ and health care professionals’ trust in

the secrecy of a privileged process -- so needed for the PSA

process to work -- implicitly resulted in privileged protection

no matter the ultimate outcome of the review process.

    Importantly, the privileges provided in the PSA do not bar

the discovery or admission into evidence of information that

would otherwise be discoverable or admissible.   Even though

particular information, materials, or documents may have been

developed in the process either of self-critical analysis or

reporting a SPAE to the DOH, such material may nevertheless be

discoverable and admissible if it is obtainable from any other

source or in “any . . . context other than those specified” in

the PSA.   
N.J.S.A. 26:2H-12.25(h).

                                23
     Relatedly, the PSA provides that its provisions do not

change the discoverability of information or documents obtained

from other sources, or in other contexts, as provided in the

Appellate Division’s opinion in Christy, issued prior to the

PSA’s enactment.   
N.J.S.A. 26:2H-12.25(k); Christy, 
366 N.J.

Super. at 544-45 (holding, contrary to hospital’s claim of

privilege, that plaintiff was entitled to “purely factual”

content from hospital’s peer-review report but not to

deliberative material).7   The Legislature’s express

acknowledgment of that decision, as well as its nod to documents

obtained through sources other than the PSA’s process of self-

critical analysis, leaves no doubt of that Branch’s respect for

the importance of discovery in ensuring the fair resolution of

litigation brought before courts.

                                B.

     Initially, we note that the trial court was well within

proper judicial bounds when examining the facts underlying the

claim of privilege in this case.     When a requesting party

demands information or documents over which the opposing party

claims a privilege, the responding party may withhold that

7  In Christy, an Appellate Division panel balanced the
“plaintiff’s right to discover information concerning his care
and treatment” against the “public interest to improve the
quality of care and help to ensure that inappropriate
procedures, if found, are not used on future patients.” 
366 N.J. Super. at 541.
                                24
information or document as long as it expressly asserts the

claimed privilege and details the nature of the information

withheld.    R. 4:10-2(e)(1) (providing for withholding of

requested privileged information); R. 4:17-1(b)(3) (providing

that party need not reveal privileged information in response to

interrogatory as long as privilege is invoked according to Rule

4:10-2(e)(1)).   When a requesting party challenges an assertion

of privilege, the court must undertake an in camera review of

the purportedly privileged document or information and make

specific rulings as to the applicability of the claimed

privilege.   See Seacoast Builders Corp. v. Rutgers, 
358 N.J.

Super. 524, 542 (App. Div. 2003) (discussing basic pre-trial

discovery principles).

    Here, defendants invoked the PSA’s self-critical-analysis

privilege relating to DCP-2.     In order to assess the basis for

the privilege, it was incumbent on the trial court to review, in

camera, whether the privilege was properly invoked and whether

the statutory privilege did, in fact, bar the information

plaintiff sought.    See ibid.   It was what came next that is

problematic.

    The claim of privilege asserted here alerted the trial

court to a set of facts underlying CMH’s self-critical analysis.

Based on those facts, the trial court determined that plaintiff

was subjected to a SPAE and that the hospital erred in

                                  25
concluding otherwise.     From that conclusion, the court

determined that CMH was required to turn over a redacted DCP-2

and report the event to the DOH because the PSA required

reporting of SPAEs to both the DOH and the patient.     Although

the trial court correctly determined that it could review in

camera the facts underlying what the hospital concluded was not

a SPAE, we hold that the court exceeded its authority, first in

declaring that a SPAE had occurred and then in issuing its

related orders that CMH disclose to plaintiff a redacted version

of DCP-2 and report the event to the DOH.

                                  1.

    The Legislature inserted no role for a trial court to play

in reviewing the SPAE determination made by a patient safety

committee of a health care facility.    By contrast, the PSA

provides a regulatory oversight role for the DOH.    The

Legislature vested enforcement of the PSA in the hands of the

Commissioner of Health.    
N.J.S.A. 26:2H-12.25(j) (vesting power

in Commissioner of Health to “adopt such rules and regulations

necessary to carry out the provisions of [the PSA]”); see also

N.J.A.C. 8:43E-3.4(a)(14) (providing for civil monetary

penalties for health care facilities failing to disclose SPAEs

to DOH).   No corresponding role is explicit or implicit in the

PSA with regard to a court called upon to resolve a discovery

                                  26
dispute over a privileged document.    We decline to entangle the

courts in an essentially administrative function.

     Accordingly, we need express no opinion on what standard

should govern the determination of whether a SPAE occurred or

the related issues of causation and expert testimony.    To the

extent that the Appellate Division refined and reversed8 the

trial court’s effort to establish a proper review standard for

identifying an event under review as a SPAE, we vacate the

Appellate Division’s analysis.

                                 2.

     Although we conclude that the trial court erred in passing

judgment as to CMH’s SPAE determination, we nevertheless

consider the discovery remedy it imposed for its finding, namely

the disclosure of the redacted report.

     The language and structure of the PSA leave no reasonable

doubt about the legislative intent regarding the self-critical-

analysis privilege it authorizes.     See DiProspero v. Penn, 
183 N.J. 477, 492-93 (2005) (noting that statutory-interpretation

analysis begins with plain language of statute and that, where

language of statute is unambiguous, analysis can come to end).

The pertinent provisions of 
N.J.S.A. 26:2H-12.25 evidence an

8  The Appellate Division applied a causality analysis, which it
determined had not been met due to the absence of any expert
analysis in the record before the trial court. Brugaletta, 
448 N.J. Super. at 418-19.
                                 27
intent to encase the entire self-critical-analysis process in a

privilege, shielding a health care facility’s deliberations and

determinations from discovery or admission into evidence.

    As the Appellate Division properly held, the only

precondition to application of the PSA’s privilege is whether

the hospital performed its self-critical analysis in procedural

compliance with 
N.J.S.A. 26:2H-12.25(b) and its implementing

regulations.   Brugaletta, 
448 N.J. Super. at 414-15.   
N.J.S.A.

26:2H-12.25(g), which creates the privilege, does not condition

the privilege on the finding of a SPAE.   The subsection provides

no such limiting basis for its invocation.   By subsection (g)’s

very terms, the privilege it announces encompasses “[a]ny

documents, materials, or information developed by a health care

facility as part of [its] process of self-critical analysis”

under subsection (b).   Thus, the Legislature’s protective

privilege around the process of performing a self-critical

analysis is broad, provided procedural compliance is present.

The privilege otherwise unconditionally protects the process of

self-critical analysis, the analysis’s results, and the

resulting reports developed by a facility in its compliance with

the PSA.

    Our construction of the pertinent language is congruent

with the stated legislative findings and declarations, which

evince a clear purpose to establish a safe, non-punitive

                                28
environment within which concerns might be brought forth,

examined, and used for improvements in patient safety.     See

N.J.S.A. 26:2H-12.24(e) and (f).     To construe the statute

otherwise -- by making its protective privilege dependent on a

SPAE finding -- would be at cross-purposes with the patent

legislative desire to encourage trust and reporting by health

care facilities and their employees whenever a concern about a

near miss or adverse event comes to light.     Our construction

gives effect to all words of the statute.     See McCann v. Clerk

of Jersey City, 
167 N.J. 311, 321 (2001) (“It is a cardinal rule

of statutory construction that full effect should be given, if

possible, to every word of a statute.    We cannot assume that the

Legislature used meaningless language.”     (quoting Gabin v.

Skyline Cabana Club, 
54 N.J. 550, 555 (1969))).     And, it avoids

reaching a result that thwarts the patent overall legislative

design.   See Murray v. Plainfield Rescue Squad, 
210 N.J. 581,

592 (2012) (reaffirming that objective of statutory

interpretation is to effectuate legislative intent).

    Accordingly, as intimated through dictum in C.A., we now

hold that the finding that an event is not reportable does not

abrogate the self-critical-analysis privilege.

    Because the PSA shields the process of self-critical

analysis, beginning to end, including its outcome, the

happenstance that a reviewing court becomes convinced that an

                                29
erroneous conclusion was reached as to whether a SPAE occurred

is of no consequence to the privilege determination.

Application of the privilege to the documents developed through

self-critical analysis, regardless of the conclusion reached, is

an integral part of the legislative scheme on which courts

should be wary to transgress.   See C.A., 
219 N.J. at 473 (noting

privilege’s essential role in promoting “thorough and candid

discussions of events occurring in health care facilities”).

    In sum, we are compelled to conclude the PSA was misapplied

and the trial court’s discretion abused when it declared that a

SPAE occurred and ordered CMH to release a redacted form of DCP-

2 to plaintiff and report the event to the DOH.    See Capital

Health Sys., 
230 N.J. at 79-80.    A court may not order the

release of documents prepared during the process of self-

critical analysis.

                                IV.

    Although a court may not order release in discovery of a

report developed during self-critical analysis, even if

redacted, and although a court may not determine whether it

agrees with the health care facility’s conclusion as to whether

an adverse event constitutes a SPAE and, based on that

determination, order disclosure to the DOH, the court’s role in

resolving this discovery dispute is far from over.

                                  A.

                                  30
    Generally, a party “may obtain discovery regarding any

matter, not privileged, which is relevant to the subject matter

involved in the pending action.”      R. 4:10-2(a); see also In re

Liquidation of Integrity Ins. Co., 
165 N.J. 75, 82 (2000)

(“Generally, . . . parties may obtain discovery regarding any

non-privileged matter that is relevant to the subject of a

pending action or is reasonably calculated to lead to the

discovery of admissible evidence.”).     Discovery is available

through, among other approved means, written interrogatories.

R. 4:10-1.    We liberally construe our discovery rules “because

we adhere to the belief that justice is more likely to be

achieved when there has been full disclosure and all parties are

conversant with all available facts.”      Integrity Ins. Co., 
165 N.J. at 82.

    When a requesting party demands access to or copies of

papers in an interrogatory, the responding party may decline by

stating with specificity the reason for its noncompliance in

response to the interrogatory.   R. 4:17-5(b).    When a responding

party declines to turn over requested documents, the requesting

party may file a motion to compel discovery, R. 4:23-5(c), after

having made a good-faith attempt to meet and confer with the

responding party or having notified the responding party that

continued noncompliance with the discovery request will lead to

a motion to compel, R. 1:6-2(c).

                                 31
    In such circumstances, the court has the obligation to

resolve the discovery dispute.

                                 B.

    As we stressed earlier, the PSA did not abrogate existing

health care law and does not immunize from discovery information

that would be otherwise discoverable.   
N.J.S.A. 26:2H-12.25(h)

(“Notwithstanding the fact that documents, materials, or

information may have been considered in the process of self-

critical analysis . . . , the provisions of this act shall not

be construed to increase or decrease, in any way, the

availability, discoverability, admissibility, or use of any such

documents, materials, or information if obtained from any source

or context other than those specified in this act.”);   N.J.A.C.

8:43E-10.9(e) (noting that PSA implementing regulations “shall

not be construed to increase or decrease, in any way, the

availability, discoverability, admissibility or use of any

documents, materials or information otherwise available from

other sources merely because the documents, materials or

information were presented during proceedings of the patient or

resident safety committee”).

    Part and parcel of defendants’ argument was the assertion

that, although they did not directly disclose the events

underlying the trial court’s SPAE determination to plaintiff,

they did turn over in discovery plaintiff’s non-privileged

                                 32
medical records, which contain documents detailing the events

underlying the patient safety committee’s, and the trial

court’s, SPAE assessments.   Indeed, the record before us

discloses that among the thousands-of-pages-long patient

records, there are notations across several pages that, when

read together, reveal the nature of the events underlying the

divergent SPAE determinations of the committee and the trial

court.   Those notations are in plaintiff’s medical records

pursuant to health care law requirements concerning patient

recordkeeping.   See N.J.A.C. 8:43G-15.2(e) (mandating inclusion

in medical records of “[a]ny adverse incident”9); 
N.J.S.A. 26:2H-

12.8 (providing non-exhaustive list of patient rights including,

under subsection (c), patient’s right “[t]o obtain from the

physician complete, current information concerning his

9  “Adverse incident” is a differently worded term than “adverse
event,” utilized and defined in the PSA and its implementing
regulations. See 
N.J.S.A. 26:2H-12.25(a); N.J.A.C. 8:43E-10.3.
The regulations do not define what constitutes an adverse
incident. Norms of statutory construction dictate that we look
to the ordinary usage of a phrase’s constituent words. See
DiProspero, 
183 N.J. at 492 (noting, in statutory-construction
context, that “[w]e ascribe to the statutory words their
ordinary meaning and significance”); see also U.S. Bank, N.A. v.
Hough, 
210 N.J. 187, 199 (2012) (“We interpret a regulation in
the same manner that we would interpret a statute.”). We
accordingly find that “adverse” is generally understood to mean
“in opposition to one’s interests: detrimental, unfavorable,”
Webster’s New Int’l Dictionary 31 (3d ed. 1981), and “incident”
means “an occurrence of an action or situation felt as a
separate unit of experience,” id. at 1142.

                                33
diagnosis, treatment, and prognosis in terms he can reasonably

be expected to understand”); N.J.A.C. 8:43G-4.1 (implementing

N.J.S.A. 26:2H-12.8 and expanding list of patient rights);

N.J.A.C. 8:43G-4.1(a)(24) and (25) (establishing patient’s right

“[t]o have prompt access to the information contained in the

patient’s medical record,” and “[t]o obtain a copy of the

patient’s medical record”).

    Here, based on a review of the record before us, including

defendants’ confidential appendix, it is apparent that plaintiff

was subjected to an adverse incident, per N.J.A.C. 8:43G-

15.2(e).   Although they did not use the term “adverse incident,”

that much is discernible from the information that plaintiff’s

doctors and CMH placed in her patient records.    That raw factual

information was documented in plaintiff’s patient records well

before the process of self-critical analysis was commenced in

her instance, which resulted in the report over which the

parties clashed as a principle of privilege.

    Although, as we have held, DCP-2 is not subject to

disclosure in discovery, even in redacted form, defendants

rightly did not object to release of the raw underlying factual

data and did, in fact, produce that material.    But, it is buried

within mounds of plaintiff’s patient records.    Specificity as to

where to find that information is lacking.     Yet, when called on

to defend against the release of privileged information,

                                34
defendants provided the court a concise step-by-step narrative,

walking the court through the relevant excerpts of plaintiff’s

patient records, to demonstrate that defendants had provided

plaintiff with the underlying non-privileged facts about her

care that sufficiently addressed the information requested in

interrogatory number five and that could be disclosed without

piercing the PSA privilege.

    The trial court redacted DCP-2 in its effort to effectuate

the release of purely factual information while simultaneously

protecting deliberative material related to CMH’s self-critical

analysis.   The court’s purpose -- to achieve a fair resolution

to a difficult discovery issue -- was proper.     However, the

court should not have used a self-critical-analysis document to

achieve its goal.

    Instead, the trial court should have used its common law

power, in administering the discovery rules, to order defendants

to provide plaintiff a narrative similar in form to the one they

presented the court.     That court-ordered remedy would have

allowed the court to balance the litigation interests of the

parties, to avoid transgressing the privilege and the salutary

purposes it is intended to achieve, and to keep the courts out

of a regulatory scheme in which we have no role vis-à-vis

declarations of SPAEs.    Plaintiff was unquestionably entitled to

the raw data contained in her patient records.    And mandating a

                                  35
narrative to steer her to that information would have required

defendants to identify, as they should have, an adverse incident

to plaintiff, see N.J.A.C. 8:43G-15.2(e), in language she could

understand, see 
N.J.S.A. 26:2H-12.8(c).

                               C.

    The Court Rules provide that an evasive or incomplete

answer given in response to a discovery request, such as an

interrogatory, is treated as a failure to answer.   R. 4:23-1(b).

Where an interrogatory requests information that can be derived

from documents to which the requesting party has access, it may

be a sufficient answer to that interrogatory to point

specifically to documents from which the requesting party can

derive a response in keeping with Rule 4:17-4(d).   That rule

provides that

         it   is   a   sufficient    answer   to   such
         interrogatory to specify the records from
         which the answer may be derived or ascertained
         and to afford to the party serving the
         interrogatory   reasonable    opportunity   to
         examine, audit or inspect such records and to
         make copies, compilations, abstracts or
         summaries.    A specification shall be in
         sufficient detail to permit the interrogating
         party to locate and to identify, as readily as
         can the party served, the records from which
         the answer may be ascertained.

         [R. 4:17-4(d).]

Importantly, the rule states that a specification is warranted

when “the burden of deriving or ascertaining the answer is

                               36
substantially the same for the party serving the interrogatory

as for the party served.”    Ibid.

     Rule 4:17-4(d), adopted in 1972, “is taken from Federal

Rule of Civil Procedure 33(c).[10]”    John H. Klock, 1B N.J.

Practice:    Court Rules Ann. cmt. 5 to R. 4:17-4 (6th ed. 2010).

The Federal Rule, the language of which was substantially

adopted in our Rule,11 provides that

            [i]f the answer to an interrogatory may be
            determined by examining, auditing, compiling,
            abstracting, or summarizing a party’s business
            records   (including   electronically   stored
            information), and if the burden of deriving or
            ascertaining the answer will be substantially
            the same for either party, the responding
            party may answer by:

                 (1) specifying the records that must be
                 reviewed, in sufficient detail to enable
                 the interrogating party to locate and
                 identify   them   as  readily   as   the
                 responding party could; and

                 (2) giving the interrogating party a
                 reasonable opportunity to examine and
                 audit the records and to make copies,
                 compilations, abstracts, or summaries.

            [Fed. R. Civ. P. 33(d).]

10 The federal option to produce business records, from which
Rule 4:17-4(d) is derived, was renumbered and is now found at
Fed. R. Civ. P. 33(d).
11 Notably, New Jersey is not the only state to substantially
adopt the text of Federal Rule of Civil Procedure 33(d) into its
Court Rules. See, e.g., Ala. R. Civ. P. 33(c); Del. Super. Ct.
Civ. R. 33(d); Mass. R. Civ. P. 33(c); Pa. R. Civ. P. 4006(b);
Tex. R. Civ. P. 197.2(c).
                                 37
    Federal Rule 33(d) is normally discussed in the context of

a party’s invocation of the rule in response to an interrogatory

and a subsequent challenge to the sufficiency of that response

by the requesting party through a motion to compel discovery.

See, e.g., United States ex rel. Landis v. Tailwind Sports

Corp., 
317 F.R.D. 592, 594 (D.D.C. 2016) (noting that matter

appeared before court in context of challenge to invocation of

option to produce business records); S.E.C. v. Elfindepan, 
206 F.R.D. 574, 576 (M.D.N.C. 2002) (“The [c]ourt normally first

becomes involved when a party files a motion to compel.”).     By

contrast, the parties here have not invoked our analogue to that

rule, Rule 4:17-4(d); instead, the records have been presented

as a matter of course, and the issue is whether the presentation

is sufficiently specific.     Nevertheless, because our Rule 4:17-

4(d) is derived from Federal Rule of Civil Procedure 33(d), “it

is appropriate to look to federal decisions for guidance” in

interpretation of the rule.     See, e.g., Adler v. Shelton, 
343 N.J. Super. 511, 523-26 (Law Div. 2001) (interpreting Rule 4:10-

2(d) by reference to federal cases discussing Federal Rule of

Civil Procedure 26).

    Generally, the federal option to provide business records

has been understood to prohibit responding parties from using

the option to refer to business records as a way to burden a

requesting party.   See 7 James W. Moore et al., Moore’s Federal

                                  38
Practice § 33.105(1) (3d ed. 1997).12   According to the Advisory

Committee on the 1970 Amendments to the Federal Rules,

          [t]he interrogating party is protected against
          abusive use of this provision through the
          requirement that the burden of ascertaining
          the answer be substantially the same for both
          sides.   A respondent may not impose on an
          interrogating party a mass of records as to
          which research is feasible only for one
          familiar with the records.

          [Fed. R. Civ. P. 33 advisory committee’s note
          to 1970 amendment.]

     When assessing the relative burdensomeness of a request

that the responding party provide some narrative answer versus

the burdensomeness of requiring the requesting party to peruse

documents to ferret out the answer, courts have looked to

whether the documents were “voluminous or incapable of being

deciphered” by the requesting party.    See Sodofsky v. Fiesta

Prods., LLC, 
252 F.R.D. 143, 148 (E.D.N.Y. 2008).   Thus, where

records are “well-organized, clear and straightforward,” a court

usually will find that the burden on the requesting party is

12 Generally, when determining whether a response utilizing
documents under Federal Rule 33(d) is sufficient, courts
consider the following: (1) whether the documents to which the
responding party points contain the information sought in the
interrogatory; (2) whether the responding party has pointed with
sufficient specificity to the documents containing the
information sought in the interrogatory; and (3) whether the
burden on the responding party to produce a narrative response
is the same as the burden on the requesting party to look to the
referenced documents and derive the requested information
therefrom. Sodofsky v. Fiesta Prods., LLC, 
252 F.R.D. 143, 147
(E.D.N.Y. 2008).
                                39
equal to that of the responding party and, therefore, permit a

responding party to answer an interrogatory by mere reference to

business records.   See id. at 148-49.   But more, in the form of

specification, explanation, or narrative, may be required.

    The United States Court of Appeals for the Third Circuit,

applying the federal analogue to our rule, found in Al Barnett &

Son, Inc. v. Outboard Marine Corp. that invocation of the option

to refer to business records in response to an interrogatory

placed a heavier burden on the requesting party where “each

[responding] party served with interrogatories was more familiar

with his bookkeeping methods and records than was the

[requesting party].”   
611 F.2d 32, 35 (3d Cir. 1979).     In that

matter, the defendant served interrogatories requesting

financial information relating to the plaintiff’s antitrust

damages and the responding party attempted to invoke Federal

Rule 33’s option to produce business records.    Id. at 34.   The

court there found that because “[m]any of the records were

handwritten, and apparently difficult to read,” and the

responding parties were more familiar with the records, it was

more burdensome on the requesting party to derive the requested

information from the documents than it was for the responding

party to extract that same information and provide it to the

requesting party.   Id. at 35.   Thus, in that case, the

responding party was ordered to provide an accompanying

                                 40
narrative response.   Id. at 34-35; see also Sabel v. Mead

Johnson & Co., 
110 F.R.D. 553, 554, 556-57 (D. Mass. 1986)

(ordering responding party to provide narrative answer in

response to interrogatory where, initially, responding party

merely pointed to 154,000-page document).

     Although no similar reported case law exists in New Jersey,

our trial courts have the authority under Rule 4:17-4(d) to

compel a party producing documentary records to provide, with

the records, a narrative that specifies for the requesting party

where responsive information may be found.    We do not mean to

suggest that such a narrative is to be routinely provided in

discovery, but it is within the range of court-ordered remedies

that may be required to resolve a discovery dispute.   Under the

circumstances presented in this appeal, where a patient suffered

an incident adverse to her interests and identifying features of

that incident are memorialized in her patient chart, the

privileged nature of one document created during the process of

self-critical analysis does not prevent a more fulsome answer to

interrogatory number five.   Although the patient chart entries

relate to a later and otherwise privileged process under the

PSA, the underlying data is not privileged.   Notwithstanding

that this setting is different from most in which an order

compelling a narrative usually arises, as noted above, we

highlight this power of the courts under the Court Rules as a

                                41
means for balancing the litigation interests in this matter,

promoting a fair trial, and securing the public policies

inherent in the maintenance of a strong self-critical-analysis

privilege under the PSA.

     Plaintiff was entitled to be informed of an adverse

incident related to her care in defendants’ response to

discovery demands because such an incident was memorialized

through various entries in her patient records.   Yet, she was

not informed of it and, notwithstanding her fifth interrogatory,

received no specification or narrative to accompany the

approximately 4500 pages of medical records turned over during

discovery that would lead her to the discrete yet interconnected

notations of the incident that appear on nine pages of that

record.   As explained earlier, see supra at ___ (slip op. at 35-

36), in these circumstances, we hold that the trial court

should, on remand, order a narrative to accompany the documents

already turned over to plaintiff in order to satisfy defendants’

obligation to provide a complete response to interrogatory

number five.13

                                V.

13 In this matter, we resolve the instant discovery dispute as
it arose. Our dissenting colleague makes broader pronouncements
about the Patient Bill of Rights that are not material to the
outcome of this case. We do not do so, and we disagree with the
dissent’s attempt to cast our opinion in such a light.
                                42
    We affirm in part and reverse in part the Appellate

Division judgment, and we remand for proceedings in accordance

with this opinion.   We do not retain jurisdiction.

     CHIEF JUSTICE RABNER and JUSTICES PATTERSON, FERNANDEZ-
VINA, SOLOMON, and TIMPONE join in JUSTICE LaVECCHIA’s opinion.
JUSTICE ALBIN filed a dissenting opinion.

                                43
                                        SUPREME COURT OF NEW JERSEY
                                          A-
66 September Term 2016
                                                   079056

JANELL BRUGALETTA,

    Plaintiff-Appellant,

         v.

CALIXTO GARCIA, D.O., STEVEN
D. RICHMAN, M.D. and PATRICK
J. HINES, M.D.,

    Defendants,

         and

CHILTON MEMORIAL HOSPITAL,

    Defendant-Respondent.

    JUSTICE ALBIN, dissenting.

    Plaintiff received treatment and care at Chilton Memorial

Hospital for serious medical illnesses, including a flesh-eating

bacterial infection.   Plaintiff’s physician ordered a course of

antibiotics to address her critical medical condition.   Despite

that order, health care professionals at Chilton failed to

administer doses of the antibiotics for a period of time.    No

one at Chilton told the plaintiff-patient about this serious

lapse in her treatment.    The information, though not easy to

find in plaintiff’s 4500-page medical chart, was released in

discovery after plaintiff filed a medical malpractice lawsuit,

which did not identify the missed doses.

                                 1
    Unlike the majority, I would make clear that the patient

had a right to be told about the lapse in her treatment at the

time it occurred and in a way that she reasonably could have

understood.   The patient’s right to know is not dependent on her

filing a medical malpractice lawsuit or requesting the

information in a well-crafted interrogatory question.     The

patient’s affirmative right to know is enshrined in the public

policy of this State by laws passed by the Legislature.

    In enacting the Patient Bill of Rights, the Legislature

conferred on a patient admitted to a hospital the right to know

“complete, current information concerning his diagnosis,

treatment, and prognosis in terms he can reasonably be expected

to understand.”   
N.J.S.A. 26:2H-12.8(c).   The Patient Safety

Act, 
N.J.S.A. 26:2H-12.23 to -12.25c, must be reconciled with

the Patient Bill of Rights, for both are part of a larger

statutory scheme known as the Health Care Facilities Planning

Act, 
N.J.S.A. 26:2H-1 to -26.   The Patient Safety Act -- like

the Patient Bill of Rights -- confers on a patient the right to

know critical information about her care and treatment.     To that

end, the Patient Safety Act specifically provides that a health

care facility must inform a patient that she has been “affected

by a serious preventable adverse event . . . no later than the

end of the episode of care, or, if discovery occurs after the

end of the episode of care, in a timely fashion.”   N.J.S.A.

                                 2
26:2H-12.25(d); see also N.J.A.C. 8:43E-10.7(a) (“A health care

facility shall ensure that a patient . . . is informed of the

following:    (1) Any serious preventable adverse event that

affected the patient[.]”).

    The majority has written out of the statute this important

patient right by declaring that a court is not empowered to

order a health care facility to disclose to a patient that she

has suffered a serious preventable adverse event.    See ante at

___ (slip op. at 26) (“The Legislature inserted no role for a

trial court to play in reviewing the [serious-preventable-

adverse-event] determination made by a patient safety committee

of a health care facility.”).    In effect, the majority has made

health care facilities the final judge of whether a patient has

suffered a serious preventable adverse event.    The majority

offers no authority, statutory or case law, for sweeping away

the right of judicial review -- the most elemental court

function.    Nor has the majority adequately explained why the

Patient Bill of Rights does not stand as an independent basis

for disclosure, whether an adverse event was serious and

preventable or not.    Neither the trial court nor the Appellate

Division entertained any question about the role of judicial

review in this process, even though the Appellate Division

concluded that the trial court erred in its determination that a

serious preventable adverse event occurred in this case.

                                  3
    I agree with the majority that “[p]laintiff was entitled to

be informed of an adverse incident related to her care in

defendants’ response to discovery demands because such an

incident was memorialized through various entries in her patient

records.”   Ante at ___ (slip op. at 42); see N.J.A.C. 8:43G-

15.2(e) (“Any adverse incident, including patient injuries,

shall be documented in the patient’s medical record.”).

However, plaintiff was entitled to that information, even if it

had not been entered in her patient records as required by

N.J.A.C. 8:43G-15.2(e), and even if she had not demanded the

information in a medical malpractice lawsuit pursuant to the

Patient Bill of Rights.   The majority’s crabbed interpretation

of the Patient Safety Act erodes significant rights the

Legislature conferred on patients.

    In my view, sufficient credible evidence in the record

supports both the trial court’s conclusion that a serious

preventable adverse event occurred and its order disclosing the

information in redacted form.   Under the Patient Safety Act,

that information could not be directly used in the lawsuit

because the information was generated through the self-critical-

analysis process.   
N.J.S.A. 26:2H-12.25(g)(1).   I agree with the

majority that, pursuant to that Act, the health care facility

waives the privilege only if it does not follow the self-

critical-analysis procedures set forth in the statute.    Ante at

                                4
___ (slip op. at 28).   The trial court clearly erred in finding

that a health care facility waives the self-critical-analysis

privilege if it acts “arbitrarily” by not disclosing information

required by the Patient Safety Act.    Even if the event was not

serious and preventable, however, it certainly was adverse and

subject to disclosure under the Patient Bill of Rights.1

     Ultimately, by requiring the hospital to provide a

forthright narrative in response to an interrogatory question,

the majority’s remedy will provide this plaintiff with easier

access to critical patient information buried in mounds of

discovery.   But in the next case, and other cases, where the

critical patient information is not released in discovery or

made part of the patient’s record, the majority, by its

expansive reading of the privilege in the Patient Safety Act,

may have diminished the patient’s right to know.

     To be sure, the self-critical-analysis privilege in the

Patient Safety Act plays an important role in fostering and

encouraging candor among health care professionals and therefore

in critiquing their performances and improving the delivery of

medical services for all patients.    The self-critical-analysis

privilege will bar a plaintiff-patient from directly introducing

1  Nothing in the Patient Bill of Rights suggests that disclosed
information about a patient’s “diagnosis, treatment, and
prognosis” is privileged.

                                 5
disclosed information about her treatment and care, recorded

pursuant to the Patient Safety Act, in a lawsuit against a

hospital or health care professionals.     
N.J.S.A. 26:2H-

12.25(g)(1).   But the privilege does not render meaningless the

Patient Bill of Rights and cannot justify withholding from the

patient critical information about serious mistakes made during

her treatment and care.   See 
N.J.S.A. 26:2H-12.8(c).    The

Patient Safety Act should not be construed to extinguish the

Patient Bill of Rights.   The statutory scheme does not sacrifice

the patient’s right to know the truth about her medical

treatment on the altar of the privilege.

    The failure of the majority to give meaning to the fullness

of the Patient Bill of Rights and the Patient Safety Act leaves

me no choice but to respectfully dissent.

                                 6