Preview
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ROBERT H. ZIMMERMAN, BAR N0. 84345 F F
123456789
Cami? DI Bum
IAN A. SCHARG, BAR NO. 285304 I I
SCHUERING ZIMMERMAN & DOYLE, LLP 9/9/2021
400 University Avenue L L
Sacramento, California
567-0400
95825-6502 E E
(916)
FAX: 568-0400 D Emalan, {Jam D
er mm
”-5”
Attorneys for Defendant ENLOE MEDICAL CENTER
SUPERIOR COURT OF CALIFORNIA, COUNTY OF BUTTE
10 JOHN O'CONNELL, N0. 18CV00806
II Plaintiff, Assigned to the Honorable Judge
Tamara L. Mosbarger for All
12 vs. Purposes
13 ENLOE MEDICAL CENTER; ALLISON DECLARATION OF KATHY CAWTHON
GUSTER, RN; NORTH VALLEY SURGICAL IN SUPPORT OF OPPOSITION TO
I4 DERRON LUDWIG, M.D., PLAINTIFF’S MOTION TO COMPEL
eta .,
ASSIOCIATES; FURTHER RESPONSES TO SPECIAL
15 INTERROGATORIES, SET I7 AND
Defendants. RESPONSES TO RFP SETS 6
16 m%T%—IER
I7 Date: September 22, 2021
Time: 9:00 a.m.
l8 Dept: I
I9 Complaint tiled: February 13,2018
Trial Date: October 18, 2021
20
21 I,KATHY CAWTHON, declare:
22 I. I know the facts set forth herein from my own personal knowledge. If
23 called upon to testify in this action as to the matters set forth herein, l could and would
24 competently testify thereto.
25 2. I am the Director of Quality 8: Safety/Medical Staff Services at Enloe
26 Medical Center. l am responsible for Enloe Medical Center's patient safety incident report
27 process, peer review, and investigations. l refer reports to the appropriate regulatory and
28 state agencies as defined by those regulatory bodies. l am responsible for reporting
0l384l09.WPD l
DECLARATION OF KATHY CAWTHON ISO ENLOE’S OPPOSITION TO PLAINTIFFS MTC
incidents to the board of trustees through the Board Quality Committee.
1234567009
3. Enloe Medical Center has adopted a Patient Safety Events policy that
outlines the for identifying, responding to, investigating and reporting the
procedure
occurrence of event that is outside the scope of normal operations for the
any
organization ("occurrences") (Attached hereto as Exhibit A is a true and correct copy of
Patient Events policy.) Enloe Medical Center has also adopted an incident
Safety
that outlines to report occurrences. (Attached hereto as
reporting policy procedures
Exhibit B is a true and correct copy of Incident Reporting policy.)
4. Included within the definition of occurrences is any incident or condition
10 that could have resulted or did result in harm to a patient. An occurrence can be the result
ll of a defective or process design, a system breakdown, equipment failure, or
system
12 human error.
13 5. Enloe Medical Center will investigate the source of any occurrence and
14 initiate mitigating actions as indicated.
and
15 6. Quality and Safety will review the circumstances of the occurrences
16 determine the event review process. Certain occurrences warrant initiation of a
l7 review team that will review the matter for case review Adverse Event
preliminary
and
l8 reporting criteria, preparation of an action plan, recommendations for improvements,
19 submission of the results to Quality Committees.
20 7. Enloe Medical Center will report these occurrences to CDPH no later
21 than five days after they have been detected. The patient, or the party responsible for the
of
22 patient, shall not be provided with a copy of the report. The report to CDPH is not part
23 the patient‘s medical record and is maintained under Evidence Code section 1157
24 protection.
25 8. The purpose of the occurrence reporting policy is to define the process
26 for identifying, reporting, and responding to any occurrence that is not consistent with
27 routine hospital operations or situations that may potentially or actually result in injury,
28 harm, or loss to any patient, visitor, student, volunteer, medical staff or employee of Enloe
01384109.WPD 2
DECLARATION OF KATHY CAWFHON ISO ENLOE’S OPPOSITION TO PLAINTIFFS MTC
Medical Center.
1234567009
9. The purpose of the occurrence report is to gather objective information
and facts about the events that occurred outside of regular hospital operations, allow for
objective review of care provided, offer education and develop ongoing performance
strategies to ensure all patients receive high quality of care.
10. The manager of the department where the event occurred is responsible
for ensuring a entered into the MIDAS Risk Incident Report module within 72
report is
hours of the event. The department manager will complete the initial investigation and
documentation of the event within seven days.
IO 1l. Enloe Medical Center inputs any information which would not be put into
II a patient’s medical record concerning patient safety and quality improvement into the
I2 MIDAS management system. This is an internal documentation system used
hospital
I3 exclusively for documenting and recording quality concerns/patient safety concerns.
I4 l2. No copies or printouts of an occurrence report can be made for any
nor
15 purpose. ln addition, no reference to the report is to be made in the medical records,
16 shall any reference be made that one has been or will be completed or submitted.
17 13. Data and information derived from the collective submission of occurrence
18 reports will be reported on an ongoing basis to the appropriate board and medical staff
19 committees that monitor organization performance to ensure risk reduction strategies are
20 implemented to reduce the number of events.
21 14. Based on my review of plaintiff‘s request for production of documents, it
22 is my understanding No. 229 seeks information that is protected by Evidence Code section
23 I157. These Patient Safety Work Product records for these types of events includes
24 analysis, potential opportunities for improvement, comparisons to identify trends,
25 identification of any contributing and mitigating factors, and are also reported to various
26 medical staff and organizational committees as appropriate. These types of events fall
27 within the reporting structure of the organization and medical staff and are protected by
28 Evidence Code section 1157 and Collaborative Healthcare Patient Safety Organization
01384109.WPD 3
DECLARATION OF KATHY CAWI‘HON ISO ENLOE’S OPPOSITION TO PLAINTIFFS MTC
1234567009
(CHPSO).
15. 1n accordance with the principles and policies outlined above, request
No. 229 seeks proceedings and records of organized committees of medical staffs in
or of a peer review body, as defined in section 805 of the Business and
hospitals,
Professions Code, and are protected under Evidence Code section 1157, and under the
Patient Safety Work Product protections of the Collaborative Healthcare Patient Safety
Organization (CHPSO), having the responsibility of evaluation and improvement of the
quality of care rendered in the hospital, or for that peer review body.
16. Based on my review of plaintiff‘s special interrogatories, set seventeen, it is
10 my understanding lnterrogatories 368-378 requested information concerning the following
ll from April 26, 2006 to the present: 1) placement of erroneous information into a patient’s
I2 electronic medical record (“EMR”), 2) when Defendant’s employee admitted to placing
l3 erroneous information into a patient’s EMR, and 3) Defendant’s methodologies for
l4 determining whether any erroneous entries were made to a patient’s EMR. In accordance
15 with the principles and policies outlined above, these interrogatories seek information
l6 concerning proceedings and records of organized committees of medical staffs in
l7 hospitals, or of a peer review body, as defined in section 805 of the Business and
18 Professions Code, and are protected under Evidence Code section 1157, and under the
19 Patient Safety Work Product protections of the Collaborative Healthcare Patient Safety
20 Organization (CHPSO), having the responsibility of evaluation and improvement of the
21 quality of care rendered in the hospital, or for that peer review body.
22 l declare under penalty of perjury under the laws of the State of California that the
23 foregoing is true and correct, and if called to testify, l could competently do so.
24 Executed this day of September, 2021, at Chico, California.
25 /s/Kathy Cawthon
26
KATHY CAWTHON
27
28
01384109.WPD 4
DECLARATION OF KATHY CAWTHON ISO ENLOE’S OPPOSITION TO PLAINTIFFS MTC
Preview
Sumac: (hurt d {:aiam in ROBERT H. ZIMMERMAN, BAR N0. 84345 F F 123456789 Cami? DI Bum IAN A. SCHARG, BAR NO. 285304 I I SCHUERING ZIMMERMAN & DOYLE, LLP 9/9/2021 400 University Avenue L L Sacramento, California 567-0400 95825-6502 E E (916) FAX: 568-0400 D Emalan, {Jam D er mm ”-5” Attorneys for Defendant ENLOE MEDICAL CENTER SUPERIOR COURT OF CALIFORNIA, COUNTY OF BUTTE 10 JOHN O'CONNELL, N0. 18CV00806 II Plaintiff, Assigned to the Honorable Judge Tamara L. Mosbarger for All 12 vs. Purposes 13 ENLOE MEDICAL CENTER; ALLISON DECLARATION OF KATHY CAWTHON GUSTER, RN; NORTH VALLEY SURGICAL IN SUPPORT OF OPPOSITION TO I4 DERRON LUDWIG, M.D., PLAINTIFF’S MOTION TO COMPEL eta ., ASSIOCIATES; FURTHER RESPONSES TO SPECIAL 15 INTERROGATORIES, SET I7 AND Defendants. RESPONSES TO RFP SETS 6 16 m%T%—IER I7 Date: September 22, 2021 Time: 9:00 a.m. l8 Dept: I I9 Complaint tiled: February 13,2018 Trial Date: October 18, 2021 20 21 I,KATHY CAWTHON, declare: 22 I. I know the facts set forth herein from my own personal knowledge. If 23 called upon to testify in this action as to the matters set forth herein, l could and would 24 competently testify thereto. 25 2. I am the Director of Quality 8: Safety/Medical Staff Services at Enloe 26 Medical Center. l am responsible for Enloe Medical Center's patient safety incident report 27 process, peer review, and investigations. l refer reports to the appropriate regulatory and 28 state agencies as defined by those regulatory bodies. l am responsible for reporting 0l384l09.WPD l DECLARATION OF KATHY CAWTHON ISO ENLOE’S OPPOSITION TO PLAINTIFFS MTC incidents to the board of trustees through the Board Quality Committee. 1234567009 3. Enloe Medical Center has adopted a Patient Safety Events policy that outlines the for identifying, responding to, investigating and reporting the procedure occurrence of event that is outside the scope of normal operations for the any organization ("occurrences") (Attached hereto as Exhibit A is a true and correct copy of Patient Events policy.) Enloe Medical Center has also adopted an incident Safety that outlines to report occurrences. (Attached hereto as reporting policy procedures Exhibit B is a true and correct copy of Incident Reporting policy.) 4. Included within the definition of occurrences is any incident or condition 10 that could have resulted or did result in harm to a patient. An occurrence can be the result ll of a defective or process design, a system breakdown, equipment failure, or system 12 human error. 13 5. Enloe Medical Center will investigate the source of any occurrence and 14 initiate mitigating actions as indicated. and 15 6. Quality and Safety will review the circumstances of the occurrences 16 determine the event review process. Certain occurrences warrant initiation of a l7 review team that will review the matter for case review Adverse Event preliminary and l8 reporting criteria, preparation of an action plan, recommendations for improvements, 19 submission of the results to Quality Committees. 20 7. Enloe Medical Center will report these occurrences to CDPH no later 21 than five days after they have been detected. The patient, or the party responsible for the of 22 patient, shall not be provided with a copy of the report. The report to CDPH is not part 23 the patient‘s medical record and is maintained under Evidence Code section 1157 24 protection. 25 8. The purpose of the occurrence reporting policy is to define the process 26 for identifying, reporting, and responding to any occurrence that is not consistent with 27 routine hospital operations or situations that may potentially or actually result in injury, 28 harm, or loss to any patient, visitor, student, volunteer, medical staff or employee of Enloe 01384109.WPD 2 DECLARATION OF KATHY CAWFHON ISO ENLOE’S OPPOSITION TO PLAINTIFFS MTC Medical Center. 1234567009 9. The purpose of the occurrence report is to gather objective information and facts about the events that occurred outside of regular hospital operations, allow for objective review of care provided, offer education and develop ongoing performance strategies to ensure all patients receive high quality of care. 10. The manager of the department where the event occurred is responsible for ensuring a entered into the MIDAS Risk Incident Report module within 72 report is hours of the event. The department manager will complete the initial investigation and documentation of the event within seven days. IO 1l. Enloe Medical Center inputs any information which would not be put into II a patient’s medical record concerning patient safety and quality improvement into the I2 MIDAS management system. This is an internal documentation system used hospital I3 exclusively for documenting and recording quality concerns/patient safety concerns. I4 l2. No copies or printouts of an occurrence report can be made for any nor 15 purpose. ln addition, no reference to the report is to be made in the medical records, 16 shall any reference be made that one has been or will be completed or submitted. 17 13. Data and information derived from the collective submission of occurrence 18 reports will be reported on an ongoing basis to the appropriate board and medical staff 19 committees that monitor organization performance to ensure risk reduction strategies are 20 implemented to reduce the number of events. 21 14. Based on my review of plaintiff‘s request for production of documents, it 22 is my understanding No. 229 seeks information that is protected by Evidence Code section 23 I157. These Patient Safety Work Product records for these types of events includes 24 analysis, potential opportunities for improvement, comparisons to identify trends, 25 identification of any contributing and mitigating factors, and are also reported to various 26 medical staff and organizational committees as appropriate. These types of events fall 27 within the reporting structure of the organization and medical staff and are protected by 28 Evidence Code section 1157 and Collaborative Healthcare Patient Safety Organization 01384109.WPD 3 DECLARATION OF KATHY CAWI‘HON ISO ENLOE’S OPPOSITION TO PLAINTIFFS MTC 1234567009 (CHPSO). 15. 1n accordance with the principles and policies outlined above, request No. 229 seeks proceedings and records of organized committees of medical staffs in or of a peer review body, as defined in section 805 of the Business and hospitals, Professions Code, and are protected under Evidence Code section 1157, and under the Patient Safety Work Product protections of the Collaborative Healthcare Patient Safety Organization (CHPSO), having the responsibility of evaluation and improvement of the quality of care rendered in the hospital, or for that peer review body. 16. Based on my review of plaintiff‘s special interrogatories, set seventeen, it is 10 my understanding lnterrogatories 368-378 requested information concerning the following ll from April 26, 2006 to the present: 1) placement of erroneous information into a patient’s I2 electronic medical record (“EMR”), 2) when Defendant’s employee admitted to placing l3 erroneous information into a patient’s EMR, and 3) Defendant’s methodologies for l4 determining whether any erroneous entries were made to a patient’s EMR. In accordance 15 with the principles and policies outlined above, these interrogatories seek information l6 concerning proceedings and records of organized committees of medical staffs in l7 hospitals, or of a peer review body, as defined in section 805 of the Business and 18 Professions Code, and are protected under Evidence Code section 1157, and under the 19 Patient Safety Work Product protections of the Collaborative Healthcare Patient Safety 20 Organization (CHPSO), having the responsibility of evaluation and improvement of the 21 quality of care rendered in the hospital, or for that peer review body. 22 l declare under penalty of perjury under the laws of the State of California that the 23 foregoing is true and correct, and if called to testify, l could competently do so. 24 Executed this day of September, 2021, at Chico, California. 25 /s/Kathy Cawthon 26 KATHY CAWTHON 27 28 01384109.WPD 4 DECLARATION OF KATHY CAWTHON ISO ENLOE’S OPPOSITION TO PLAINTIFFS MTC