IN THE SUPREME COURT OF IOWA

No. 16–1009

Filed April 7, 2017

Amended June 22, 2017

DENNIS WILLARD,

Appellee,

vs.

STATE OF IOWA,

Appellant.

Appeal from the Iowa District Court for Johnson County, 

Mitchell E. Turner, Judge.

The State appeals from a district court ruling granting plaintiff’s 

motion to compel discovery. REVERSED AND REMANDED.

Thomas J. Miller, Attorney General, Jeffrey S. Thompson, Solicitor 

General, and Forrest Guddall (until withdrawal) and Anne Updegraff, 

Assistant Attorneys General, for appellant.

Matt J. Reilly of Eells & Tronvold Law Offices, PLC, Cedar Rapids, 

for appellee.

Erika Eckley, Des Moines, and T. Randall Wright of Baird Holm 

LLP, Omaha, Nebraska, for amicus curiae Iowa Hospital Association.
2

Paul Drey, Jeanine Freeman, and Allison M. Steuterman of Brick 

Gentry, P.C., West Des Moines, for amici curiae American Medical 

Association and Iowa Medical Society.
3

ZAGER, Justice.

In this interlocutory appeal, we are asked to determine whether a 

hospital’s Patient Safety Net materials are protected under the morbidity 

and mortality privilege, and whether this information is discoverable in 

this medical negligence action. Dennis Willard was seriously injured in a 

motor vehicle accident in Davenport, Iowa. After initial treatment in 

Davenport, Willard was transferred to the University of Iowa Hospitals 

and Clinics (UIHC) for further treatment. Because of the seriousness of 

his injuries, he was sedated and intubated. During his treatment at 

UIHC, Willard underwent a number of medical examinations and tests, 

one of which was an abdominal CT scan. Willard claims that while being 

transported to the CT scan and while undergoing the CT scan, UIHC was 

negligent in its handling of him. As a result, Willard claims he sustained 

an injury to his left shoulder and arm, in addition to his foot. After the

CT scan, an employee of UIHC filed a PSN form about the incident. As 

part of his lawsuit for medical negligence against the State of Iowa,1

Willard requested discovery of the PSN and related documents. The 

State objected to the disclosure of the PSN and related documents,

claiming the documents were privileged. Willard filed a motion to 

compel. After a hearing and briefing, the district court granted the

motion to compel and ordered the State to produce the documents. The 

State applied for an interlocutory appeal and for a stay of the district 

court ruling, which we granted. For the reasons expressed below, we 

reverse the district court ruling and conclude the PSN and related 

documents are privileged under the morbidity and mortality statute and

are not subject to discovery.

 1UIHC is owned, operated, and controlled by the State of Iowa.
4

I. Background Facts and Proceedings.

Dennis Willard was involved in a head-on motor vehicle accident in 

the late hours of November 3, 2011. Willard sustained significant 

injuries from the collision and was initially treated at the Genesis 

Medical Center East in Davenport, Iowa. While at Genesis, Willard 

underwent imaging studies and x-rays. One of the x-rays covered 

Willard’s left shoulder and showed no break or dislocation.

Willard was transferred to the UIHC early in the morning on 

November 4. UIHC performed more imaging studies and x-rays, and the 

follow-up x-ray of Willard’s left shoulder again showed no break or 

dislocation. While at the UIHC, Willard’s condition deteriorated, which 

required that he be sedated and intubated. Because the doctors were 

concerned that Willard had sustained internal organ damage as a result 

of the accident, he underwent an abdominal CT scan on November 6. 

Willard remained sedated and intubated during the CT scan. In order to 

perform the CT scan, the imaging technologists were required to raise

Willard’s arms above his head.

When Willard returned to his floor after the CT scan, staff noted 

that he exhibited a lack of motor response in his left arm and pain with 

range of motion. They requested an orthopedic team consult, and the 

orthopedic surgeon ordered more x-rays of Willard’s left shoulder. At 

this point, orthopedic surgeon Dr. Buckwalter diagnosed Willard with an 

anterior-inferior dislocation in the left shoulder, and he relocated it. 

Willard’s progress notes stated that orthopedics was consulted “regarding 

left anterior-inferior shoulder dislocation following a trip to CT for an 

abdominal exam.” The next day, Willard’s progress notes again stated

that orthopedics had been consulted “after he sustained a left shoulder 

dislocation in an anterior inferior direction while obtaining a CT scan.” 
5

Willard filed a petition at law and jury demand on November 24, 

2014, pursuant to the Iowa State Tort Claims Act.2 The underlying basis 

for Willard’s claim is that he was negligently handled while sedated, 

causing him to sustain injuries to his left shoulder, arm, and foot. He 

argues the State owed him a duty to exercise reasonable care in 

transporting him while sedated and the employees of the hospital

breached that duty. He asserts that the x-rays from Genesis and the xrays taken at UIHC on November 4 do not show a left shoulder 

dislocation. However, the x-ray taken after the abdominal CT scan 

shows a left shoulder dislocation, which indicates his shoulder was 

dislocated during the CT scan procedure.

During the course of discovery, Willard submitted the following 

interrogatories:

INTERROGATORY No. 6: State whether you, your agents or 

attorneys have obtained any statement, either oral or 

written, from any person having knowledge of facts relating 

to the subject matter of this action, and if so, please state:

(a) the name and address of each person giving such 

statement;

(b) whether each such statement is written or recorded 

and signed or unsigned;

(c) the date, time, and place each such statement was 

taken;

(d) the name and present address of the person taking 

each such statement;

(e) the name and address of each person having 

custody and control of such statement;

(f) the substance of each such statement.

INTERROGATORY No. 16: Was any document withheld 

under any alleged privilege? If the answer was yes, identify 

 2Iowa Code chapter 669 (2015).
6

each document for which a privilege is claimed, together with 

the following information: date, sender, recipients, recipients 

of copies, subject matter of the document, and the basis 

upon which said privilege is claimed.

Willard also made an initial request for documents seeking copies of any 

reports or memoranda relating to him, the incident referenced in his 

petition, or the injuries or damages included in his petition. In a 

supplemental request for documents, Willard requested “[a]ny PSN, 

unusual incident report or other incident report prepared by any agent or 

employee of Defendant in November 2011 that relates to or refers to 

Plaintiff.”

Willard filed the supplemental request for documents after 

deposing UIHC senior imaging technologist Cyndie Beaumont, who had 

assisted with Willard’s CT scan. During her deposition, Beaumont stated 

that she did not recall the CT scan itself, but does remember Willard 

because she learned that an incident report had been filed about the 

scan the next day. The incident report that was filed was a Patient 

Safety Net (PSN) form.

A PSN is an electronic form that allows UIHC employees to enter 

information about events that raise a safety concern for patients. The 

UIHC encourages staff to enter a PSN for any safety concern, and 

thousands of PSNs are submitted every year. UIHC employees are 

informed that PSNs are confidential and protected. A submitted PSN 

may be used for a number of purposes, including but not limited to 

morbidity and mortality studies, a source for UIHC staff to review events, 

a source to determine trends, information to identify topics for research 

or conference presentations, and literary reviews. 

Once a PSN is entered, it is submitted to an electronic database 

and reviewed by the UIHC quality department. This initial review is 
7

conducted daily, and the department determines where to route each 

submitted PSN. The department may submit the PSN for review to a 

quality officer or the safety oversight team. The PSN may also be routed 

to the patient safety issues group of a specific department, such as 

anesthesiology.

The safety oversight team is a multidisciplinary group that reviews 

PSNs to identify trends and revises hospital policy based on those trends. 

A PSN is submitted for review to the safety oversight team if it is a 

“serious adverse event” or a “sentinel event.” A serious adverse event is 

an event that requires special intervention because the potential for 

serious injury is high. A sentinel event is a serious adverse event that 

involved death or serious physical or psychological injury, or a serious 

adverse event that involved a high risk of death or serious physical or 

psychological injury. Once a PSN based on a serious adverse event or a 

sentinel event is submitted to the safety oversight team, the team 

determines whether a Root Cause Analysis (RCA) is required. 

If an RCA is required, a group of content experts studies the 

underlying event and makes conclusions about the event and the 

contributing causes. The group then provides recommendations for 

reducing the risk of the same safety issue occurring in the future. 

Finally, the group prepares an action plan based on the 

recommendations and implements it. 

The PSN system does not track how PSNs are used, so it is 

unknown whether Willard’s specific PSN was used for morbidity and 

mortality studies, research, an RCA, or quality improvement.
8

On March 14, 2016, Willard filed a motion to compel the PSN and 

related pages.3 The State acknowledged that it had in its possession 

twenty-four pages of materials that included the PSN and related 

documents, but it objected to the disclosure of the material. The State 

resisted Willard’s motion, arguing that the documents were privileged 

under the morbidity and mortality privilege contained in Iowa Code 

sections 135.40 through 135.42. See Iowa Code §§ 135.40–.42 (2015). 

Further, the State argued the documents were not discoverable under 

section 135.42. The district court held an evidentiary hearing and 

ordered the State to produce the PSN and related documents for an in 

camera review.

On June 9, the district court granted Willard’s motion to compel.

The district court found that the State failed to meet its burden to 

establish the PSN was subject to the morbidity and mortality privilege

contained in section 135.40. The district court found that the morbidity 

and mortality statute was created for situations where data is collected 

for a study, but that the State did not meet its burden to establish that 

the PSN was created or used for the course of any study for the purpose 

of reducing morbidity or mortality. The district court also found that 

section 135.41 did not apply because the case did not involve a third 

party. The district court found that section 135.42 dealt with the issue 

of admissibility, but not discoverability, of the requested documents. The 

district court found that because discovery rules are to be liberally 

construed and the information contained in the documents could 

 3Originally, the State acknowledged it had possession of a four-page PSN and 

associated eight pages. The State later discovered a second four-page PSN and related 

eight pages. The State’s discovery response was supplemented to acknowledge that it 

had in its possession the twenty-four pages but objected to their disclosure.
9

reasonably lead to admissible evidence, the PSN was subject to discovery. 

The district court also found that the attorney–client and work-product 

privileges did not apply. The district court ordered the State to produce 

the PSN and related documents to the plaintiff within twenty days. It 

also ordered Willard not to disclose the documents to anyone except his 

expert witnesses. Any other proposed disclosures would need the

approval of the district court.

On June 13, the State filed an application for interlocutory appeal 

and motion for stay of the district court ruling to produce the PSN and 

related documents, which we initially denied. On June 17, the State filed 

a motion for review of the denial. We stayed enforcement of the district 

court ruling pending our ruling on the motion for review. On June 24, 

we granted the application for interlocutory appeal and stayed further 

proceedings below. 

II. Standard of Review.

We review a district court’s discovery decisions for an abuse of 

discretion. Jones v. Univ. of Iowa, 836 N.W.2d 127, 139 (Iowa 2013). An 

abuse of discretion exists when the district court’s ruling “rests upon 

clearly untenable or unreasonable grounds.” Id. (quoting Lawson v. 

Kurtzhals, 792 N.W.2d 251, 258 (Iowa 2010)). “A ground or reason is 

untenable . . . when it is based on an erroneous application of the law.” 

Sioux Pharm., Inc. v. Eagle Labs., Inc., 865 N.W.2d 528, 535 (Iowa 2015) 

(quoting Office of Citizens’ Aide/Ombudsman v. Edwards, 825 N.W.2d 8, 

14 (Iowa 2012)). “To the extent we . . . engage in statutory interpretation, 

our review is for correction of errors at law.” DuTrac Cmty. Credit Union 

v. Hefel, ___ N.W.2d ___, ___ (Iowa 2017).
10

III. Analysis.

On appeal, the State argues that the morbidity and mortality 

confidentiality privilege applies to the PSNs at issue here pursuant to 

Iowa Code sections 135.40–.42.4 The State further argues that the PSN 

and related documents are not subject to discovery based on the specific 

language of Iowa Code section 135.42. When a privilege is statutory, 

“the terms of the statute define the reach of the privilege.” Carolan v. 

Hill, 553 N.W.2d 882, 886 (Iowa 1996). In order to determine whether 

the PSNs are entitled to the privilege, statutory interpretation must be 

employed. “The purpose of statutory interpretation is to determine the 

legislature’s intent.” State v. Howse, 875 N.W.2d 684, 691 (Iowa 2016) 

(quoting Schaefer v. Putnam, 841 N.W.2d 68, 75 (Iowa 2013)).

A. Background. In 2000, the Institute of Medicine (IOM)

published a report entitled To Err Is Human: Building a Safer Health 

System, which analyzed common medical errors and how to prevent 

them. Inst. of Med., To Err Is Human: Building a Safer Health System

(Linda T. Kohn, Janet M. Corrigan, & Molla S. Donaldson eds., 2000)

[hereinafter To Err Is Human]; see also Tibbs v. Bunnell, 448 S.W.3d 796, 

800 (Ky. 2014). The report estimated between 44,000 and 98,0005

people die annually in hospitals as a result of preventable medical errors. 

To Err Is Human, at 26. The majority of these preventable errors “were 

not the result of personal recklessness but rather resulted from faulty 

systems, processes, and conditions.” Lee Med., Inc. v. Beecher, 312 

 4Neither Willard nor the district court dispute that the statute creates a 

privilege.

5At the time the report was published, this would have made preventable 

hospital deaths one of the leading causes of death in the United States, with even the 

lower number surpassing deaths due to motor vehicle accidents, breast cancer, or 

AIDS. To Err Is Human, at 26–27.
11

S.W.3d 515, 534 (Tenn. 2010). The report recommended that hospitals 

adopt a four-tiered system to make the health system safer for patients. 

To Err Is Human, at 6. The identified four tiers are (1) enhancing 

knowledge of patient safety, (2) identifying medical errors through both 

mandatory and voluntary reporting systems, (3) raising performance 

standards and expectations for improvement, and (4) adopting safety 

systems to ensure patient safety practices. Id.

Following the publication of the report, Congress enacted the 

Patient Safety and Quality Improvement Act of 2005 (PSQIA), Pub. L. No. 

109-41, 119 Stat. 424 (codified at 42 U.S.C. 299b-21 to 299b-26 (2012)). 

“The Patient Safety Act ‘announces a more general approval of the 

medical peer review process and more sweeping evidentiary protections 

for materials used therein.’ ” Dep’t of Fin. & Prof’l Regulation v. Walgreen 

Co., 970 N.E.2d 552, 557 (Ill. App. Ct. 2012) (quoting KD ex rel. 

Dieffenbach v. United States, 715 F. Supp. 2d 587, 595 (D. Del. 2010)). 

The purpose of the PSQIA was “to encourage the reporting and analysis 

of medical errors and health care systems by providing peer review 

protection of information reported to patient safety organizations for the 

purposes of quality improvement and patient safety.” Tibbs, 448 S.W.3d 

at 801 (quoting H.R. Rep. No. 109–197 (2005)). The protections included 

in the Act were intended to apply to documents or communications that 

constitute “patient safety work product.” Id.

The Iowa Legislature originally enacted morbidity and mortality 

study statutes in 1963 and amended the statutes in 2006, after the 

publication of the IOM report and the enactment of the PSQIA. Compare 

Iowa Code §§ 135.40–.42 (1966), with id. §§ 135.40–.42 (2006). These 

provisions provide,
12

135.40. Collection and distribution of information.

Any person, hospital, sanatorium, nursing or rest 

home, or other organization may provide information, 

interviews, reports, statements, memoranda, or other data 

relating to the condition and treatment of any person to the 

department, the Iowa medical society or any of its allied 

medical societies, the Iowa osteopathic medical association, 

any in-hospital staff committee, or the Iowa healthcare 

collaborative, to be used in the course of any study for the 

purpose of reducing morbidity or mortality, and no liability 

of any kind or character for damages or other relief shall 

arise or be enforced against any person or organization that 

has acted reasonably and in good faith, by reason of having 

provided such information or material, or by reason of 

having released or published the findings and conclusions of 

such groups to advance medical research and medical 

education, or by reason of having released or published 

generally a summary of such studies.

. . . . 

135.41. Publication.

The department, the Iowa medical society or any of its 

allied medical societies, the Iowa osteopathic medical 

association, any in-hospital staff committee, or the Iowa 

healthcare collaborative shall use or publish said material 

only for the purpose of advancing medical research or 

medical education in the interest of reducing morbidity or 

mortality, except that a summary of such studies may be 

released by any such group for general publication. In all 

events the identity of any person whose condition or 

treatment has been studied shall be confidential and shall 

not be revealed under any circumstances. A violation of this 

section shall constitute a simple misdemeanor.

135.42. Unlawful use.

All information, interviews, reports, statements, 

memoranda, or other data furnished in accordance with this 

division and any findings or conclusions resulting from such 

studies shall not be used or offered or received in evidence in 

any legal proceedings of any kind or character, but nothing 

contained herein shall be construed as affecting the 

admissibility as evidence of the primary medical or hospital 

records pertaining to the patient or of any other writing, 

record or reproduction thereof not contemplated by this 

division.

Id. §§ 135.40–.42 (2015).
13

B. Iowa Code Section 135.40. The first issue we must address is 

whether the PSN qualifies as a morbidity and mortality study under Iowa 

Code section 135.40. The statute provides that an organization “may 

provide information, interviews, reports, statements, memoranda, or 

other data relating to the condition and treatment of any person . . . to be 

used in the course of any study for the purpose of reducing morbidity or 

mortality.” Id. § 135.40. The State argues the statute is broad enough to 

encompass the PSN documents. Willard argues that there is no evidence 

in the record that the PSN was actually used in the course of any study 

for the purpose of reducing morbidity and mortality, and therefore it is 

not protected under the statute.

When we interpret a statute, we apply well-settled principles of 

statutory interpretation: 

The purpose of statutory interpretation is to determine the 

legislature’s intent. We give words their ordinary and 

common meaning by considering the context within which 

they are used, absent a statutory definition or an established 

meaning in the law. We also consider the legislative history 

of a statute, including prior enactments, when ascertaining 

legislative intent. When we interpret a statute, we assess the 

statute in its entirety, not just isolated words or phrases. 

We may not extend, enlarge, or otherwise change the 

meaning of a statute under the guise of construction.

DuTrac, ___ N.W.2d at ___ (quoting Howse, 875 N.W.2d at 691). We 

construe a statute “liberally with a view to promoting its objects and 

assisting the parties in obtaining justice.” Star Equip., Ltd. v. State, 843 

N.W.2d 446, 455 (Iowa 2014) (quoting Lennox Indus., Inc. v. City of 

Davenport, 320 N.W.2d 575, 578 (Iowa 1982)).

Morbidity and mortality are not defined by statute. Morbidity can 

be defined as “a diseased state or symptom,” “the incidence of disease :

the rate of sickness,” or as a collection of statistics on an illness. 

Morbidity, Webster’s Third New International Dictionary (unabr. ed. 2002). 
14

Mortality can have a number of meanings, including “the death of large 

numbers : a heavy loss of life (as by war or disease),” either the whole 

sum of deaths or a proportion of deaths per population, or a “rate of loss 

or failure in a field of human endeavor.” Mortality, Webster’s Third New 

International Dictionary. Taken together with their common meanings, a 

morbidity and mortality study can be interpreted broadly to mean a 

collection of statistics or a study regarding the rates of illnesses, 

diseases, or death among a patient population.

Further, the morbidity and mortality statute has an expansive 

scope, which is demonstrated throughout the text of section 135.40. See

Iowa Code § 135.40. The statute relies on a broad range of organizations 

to provide information—“[a]ny person, hospital, sanatorium, nursing or 

rest home, or other organization.” Id. § 135.40 (emphasis added). It 

allows these groups to provide a wide array of information—“information, 

interviews, reports, statements, memoranda, or other data relating to the 

condition and treatment of any person.” Id. (emphasis added). It allows 

a wide number of organizations to be the recipient of this information—

“the [public health] department, the Iowa medical society or any of its 

allied medical societies, the Iowa osteopathic medical association, or any 

in-hospital staff committee, or the Iowa healthcare collaborative.” Id.

(emphasis added). It allows the information provided and collected “to be 

used in the course of any study for the purpose of reducing morbidity 

and mortality.” Id. (emphasis added). 

Hospitals are required to have ongoing, hospital-wide quality 

improvement programs in place that allow them to assess clinical patient 

care and nonclinical and patient-related services within the hospital, and 

to develop remedial action if necessary. Iowa Admin. Code § 481—51.3. 

Hospitals are required to have a written quality improvement plan which, 
15

among other things, may address the “accessibility and confidentiality of 

materials relating to, generated by, or [included as] part of the quality 

improvement process.” Id. § 481—51.3(4)(g). All of this indicates a 

legislative intent to encourage a wide number of individuals and 

organizations to report incidents and concerns about patient care, in a 

wide variety of formats.

A PSN clearly falls within the legislative intent of “any study for the 

purpose of reducing morbidity or mortality.” Iowa Code § 135.40. The 

PSN system allows the UIHC to keep track of patient incidents and to 

route them to the appropriate department for resolution. The PSN 

system can also result in revised policies for the hospital as a whole or

for use in studies, reports, and presentations. Similar to the purposes of 

the PSQIA, the purpose of section 135.40 is “to encourage the reporting 

and analysis of medical errors and health care systems by providing peer 

review protection of information reported to patient safety organizations 

for the purposes of quality improvement and patient safety.” Tibbs, 448 

S.W.3d at 801 (quoting H.R. Rep. No. 109–197 (2005)). We find that the 

PSN and related documents are afforded a privilege as morbidity and 

mortality information to be used in a study as defined in Iowa Code 

section 135.40.

C. Iowa Code Section 135.41. The second issue we must 

address is whether Iowa Code section 135.41 has any applicability to the 

privilege asserted here. The district court found that the State failed to 

establish a privilege under this section because the case does not involve 

a third party being asked to produce records, but rather Willard himself

requesting the documents. The district court found that the privilege 

only protects against disclosures to third parties.
16

Iowa Code section 135.41 governs the publication of studies that 

include material regarding morbidity and mortality. Id. § 135.41. The 

language of the statute is limiting. It limits the use of morbidity and 

mortality information with mandatory language. Id. The organizations 

authorized to use the information “shall use or publish said material only 

for the purpose of advancing medical research or medical education in 

the interest of reducing morbidity or mortality.” Id. (emphasis added). 

The statute also includes a permissive clause; however, this language is 

still limiting. The organizations that publish material in the interest of 

reducing morbidity or mortality may release a summary of the study for 

general publication. Id. We found in Burton v. University of Iowa Hosps.

& Clinics that the hospital has the discretion to determine whether to 

produce these summaries. 566 N.W.2d 182, 187–88 (Iowa 1997).

The statute does not make a distinction between a third party 

request for information and Willard’s request for information, and we 

decline to read such a distinction into the statute. Furthermore, Willard

is not requesting a summary of any morbidity and mortality study, but 

the PSNs themselves. We find that the release of the PSN is not required 

by section 135.41.

D. Iowa Code Section 135.42. The final question we must 

answer is whether the PSN is subject to discovery under section 135.42. 

The statute provides that information obtained under the morbidity and 

mortality statutes “shall not be used or offered or received in evidence in 

any legal proceedings.” Iowa Code § 135.42. The State argues this 

should be interpreted to mean morbidity and mortality information

cannot be used in any legal proceedings, including discovery. Because

“shall not be . . . offered or received in evidence” already covers 

information utilized during trial, the State argues that any other 
17

definition would render the words “shall not be used” superfluous, and 

therefore it should be interpreted to include discovery. Willard argues 

that while the statute provides that the documents may not be used, 

offered, or received in evidence, it does not preclude the documents from 

being discoverable.

The district court has wide discretion in rulings on discovery. 

Carolan, 553 N.W.2d at 886. We construe discovery rules liberally in 

order to assist in the disclosure of all relevant and material information. 

Id. However, Iowa Rule of Civil Procedure 1.503 limits the scope of 

discovery to “any matter, not privileged, which is relevant to the subject 

matter involved in the pending action.” Iowa R. Civ. P. 1.503 (emphasis 

added). A party may resist discovery by demonstrating that the material 

sought is privileged, but the party resisting has the burden of 

demonstrating both that the privilege exists and that it applies. Carolan, 

553 N.W.2d at 886. We construe asserted privileges narrowly because a 

privilege is an exception to our generally liberal rules regarding discovery. 

Id. When a party asserts a privilege that is based on a statute, the words 

of the statute define the reach of the privilege. Id. Here, the State has 

demonstrated that the materials are privileged as morbidity and 

mortality information under Iowa Code section 135.40. Because the 

privilege is statutory, the words of section 135.42 define the reach of the 

privilege. Id. 

Under the doctrine of last preceding antecedent, a qualifying word 

or phrase only refers to the immediately preceding antecedent unless the 

language of the statute clearly demonstrates a contrary legislative intent. 

Iowa Comprehensive Petroleum Underground Storage Tank Fund Bd. v. 

Shell Oil Co., 606 N.W.2d 376, 380 (Iowa 2000). “[E]vidence that a 

qualifying phrase is supposed to apply to all antecedents instead of only 
18

to the immediately preceding one may be found in the fact that it is 

separated from the antecedents by a comma.” State v. Gen. Elec. Credit 

Corp. of Del., 448 N.W.2d 335, 345 (Iowa 1989) (quoting 2A Sutherland, 

Statutes and Statutory Construction § 47.33 (4th ed. 1984)).

Under this doctrine, the phrase “in evidence” only applies to the 

word “received” because it is the only word immediately preceding the 

phrase “in evidence” and there are no commas separating the words 

“used,” “offered,” and “received” in the statute. Iowa Code § 135.42. In 

applying the doctrine to the statute, we find the legislature has precluded 

the use of morbidity and mortality information under three 

circumstances. The studies or information may not be: (1) used in any 

legal proceeding, (2) offered in any legal proceeding, or (3) received in 

evidence in any legal proceeding. See id.

Additionally, when a statute is ambiguous, we may consider the 

“consequences of a particular construction” in determining the 

legislature’s intent. Id. § 4.6(5). Here, there are relevant public policy 

issues to be considered. The rationale underlying the protection of 

privileged communication from discovery “is the protection of interests 

and relationships, which rightly or wrongly, are regarded as of sufficient 

social importance to justify some sacrifice of availability of evidence 

relevant to the administration of justice.” 8 Tom Riley & Peter C. Riley, 

Iowa Practice SeriesTM, Civil Litigation Handbook, § 29:1 (2016 ed.) 

(quoting McCormick on Evidence § 72 (4th ed.)).

The overall statutory scheme regarding morbidity and mortality 

information and studies is broad. As discussed earlier, section 135.40 

encompasses a wide number of individuals and organizations that may 

provide information and a wide number of organizations that may receive 

information. Iowa Code § 135.40. It provides that information used in 
19

the course of any study intended to reduce morbidity and mortality rates 

is subject to its protection. Id. Section 135.41 is similarly broad in its 

protection of information related to morbidity and mortality. Id. 

§ 135.41. Only a summary of the studies may be released, but within

the discretion of the organization producing the study. Id.; Burton, 566 

N.W.2d at 187–88. 

We likewise find that the legislature intended section 135.42 to 

broadly cover “any legal proceeding.” Iowa Code § 135.42 (emphasis 

added). There are a number of public policy objectives underlying 

morbidity and mortality statutes. Preventable medical errors are a 

pervasive issue in hospitals across the country and decreasing the 

number of these errors is of the utmost importance. To Err Is Human, at 

26–27. The information utilized in morbidity and mortality studies is 

collected from hospital employees and is intended to track adverse 

events; sentinel events; safety issues; and any other concerns regarding 

the health, care, and safety of patients. The objective of collecting this 

information is to study adverse incidents in order to create new systems 

and methods to prevent patient safety issues in the future. The 

information provided is supplied by employees about their peers or 

supervisors. Morbidity and mortality studies are protected so employees 

are forthcoming with their concerns, issues, and criticisms.

We considered similar public policy considerations in Carolan. 553 

N.W.2d at 886. Although Carolan dealt with the confidentiality of peer 

review records, see 553 N.W.2d at 886, we nevertheless find the rationale 

similarly persuasive in the context of PSNs and related documents. We 

noted that confidentiality was imperative because

[p]eer review privileges encourage an effective review of 

medical care. If such records were privileged only when 

directed at a specific licensee, hospitals would have difficulty 
20

conducting reviews of their health care departments. 

Without the broad protections, physicians would be very 

reluctant to participate, knowing the information could 

easily be revealed in a court of law.

Id. at 886–87.

The same is true for PSNs and the related documents. There is a 

strong public policy argument for interpreting section 135.42 broadly. 

The protection afforded by the confidentiality privilege allows hospital 

staff to feel comfortable reporting any and all safety concerns because 

those reports will remain confidential and not be subject to discovery in a 

legal proceeding. This confidentiality allows hospitals to utilize PSNs to 

reduce adverse patient safety events based on preventable medical 

errors. The protection is intended to apply to documents or 

communications that constitute “patient safety work product.” We find 

that Iowa Code section 135.42 extends to prevent discovery of PSNs and 

related documents.

IV. Conclusion.

For the above reasons, we reverse the decision of the district court. 

We find that the PSN and related documents are the type of information 

covered by the morbidity and mortality statute and are therefore 

privileged under Iowa Code section 135.40. We find that Iowa Code 

section 135.41 does not apply because Willard does not seek a summary 

of the morbidity or mortality study but rather the PSN and related 

documents themselves. Finally, we find that based upon the language 

contained in section 135.42, the PSN and related documents are not 

subject to discovery.

REVERSED AND REMANDED.