| Course | HCM-3080 Healthcare Legal and Ethical Considerations |
|---|---|
| Module | Module 11 |
| Paper type | Written assignment: safety and excellence |
| Length | About 657 words, 5 pages |
| Format | APA 7 student paper |
| School | Thomas Edison State University |
| Program | B.S. in Healthcare Management |
| Updated | October 2026 |
Free sample paper for HCM 3080 Module 11
Report, Disclose, Protect, Learn: The Legal Framework After a Retained Sponge at Riverbend Community Hospital
Student Name
B.S. in Healthcare Management, Thomas Edison State University
HCM-3080: Healthcare Legal and Ethical Considerations
Mentor Name
Month Day, Year
Report, Disclose, Protect, Learn: The Legal Framework After a Retained Sponge at Riverbend Community Hospital
Eight weeks after an emergency bowel resection at Riverbend, a composite community hospital in the southern part of the state,, a 63-year-old patient returned with fever and abdominal pain. A CT scan showed a retained surgical sponge, which was removed in a second operation. The original surgery had begun as a planned procedure and changed course when the surgeon found a perforation, and the final sponge count had been recorded as correct. This paper examines the hospital's legal duties to report and disclose the event, the federal protection for its internal safety analysis, and how the law supports learning from the error.
Reporting the Event
New Jersey's Patient Safety Act requires licensed health care facilities to have a patient safety plan, to report every serious preventable adverse event to the Department of Health, and to inform the patient, or the patient's family when appropriate, of the event in a timely manner (N.J. Stat. Ann. § 26:2H-12.25). A retained foreign object after surgery is the kind of serious, preventable event the law was written for. The report must be made by the facility, not by individual clinicians, which places the responsibility on administration. The statute also gives protections for documents prepared for the patient safety process, encouraging candid internal review.
Disclosing to the Patient
The disclosure requirement reflects ethical obligations as well as legal ones. Patients have a right to know what happened to them, especially when a second operation is needed. Riverbend's disclosure was made by the surgeon and the chief medical officer together, two days after the CT scan, in a private meeting with the patient and his wife. They explained what was found, that it should not have happened, that the hospital was reviewing why and what would change, and that the costs of the second surgery would not be billed. The meeting was documented separately from the safety analysis, so the patient's record shows that disclosure occurred.
Protecting the Safety Analysis
Hospitals are more likely to investigate errors honestly if their analyses cannot easily be used against them in court. A 2005 federal statute on patient safety and quality improvement makes patient safety work product, such as analyses and deliberations developed for reporting to a listed patient safety organization, privileged and confidential, with limited exceptions; it is not subject to subpoena or discovery in civil, criminal or administrative proceedings, and it may not be admitted as evidence (42 U.S.C. § 299b-22). Riverbend reports to a patient safety organization and conducts its root cause analyses within that system. The protection covers the analysis, not the underlying facts: the medical record, the operative note and the count sheet remain discoverable, and the patient's attorney can still obtain them.
Learning From the Event
The root cause analysis identified factors that research has linked to retained objects. Gawande et al. (2003), comparing patients with retained instruments and sponges with controls, found that emergency surgery and unexpected changes in the procedure significantly increased the risk, along with higher body mass index, and that counts were less likely to have been performed in cases with retained objects. Both of the first two factors were present here. Riverbend's changes included radiofrequency-tagged sponges with a wand scan before closure for all abdominal cases, a mandatory recount whenever a procedure changes course, and a rule that a correct count does not replace imaging when a count was interrupted. These changes are possible because the analysis was candid, and the analysis was candid partly because the law protected it.
Conclusion
After a serious adverse event, the law asks the hospital to report it to the state, tell the patient the truth and learn from it, and it protects the internal analysis that makes learning possible. An administrator who understands these duties together can meet the legal requirements while strengthening the culture of safety the course's module title calls excellence.
References
Gawande, A. A., Studdert, D. M., Orav, E. J., Brennan, T. A., & Zinner, M. J. (2003). Risk factors for retained instruments and sponges after surgery. New England Journal of Medicine, 348(3), 229-235. https://doi.org/10.1056/NEJMsa021721
N.J. Stat. Ann. § 26:2H-12.25 (2024). Patient safety plan; reporting of adverse events. https://law.justia.com/codes/new-jersey/title-26/section-26-2h-12-25/
42 U.S.C. § 299b-22 (2018). Privilege and confidentiality protections. https://www.law.cornell.edu/uscode/text/42/299b-22
HCM 3080 Module 11 instructions, in plain terms
The eleventh module, Safety and Excellence, typically pairs with one of the five written assignments, each about two to three pages and focused on applying law and ethics to a real health care problem. The classroom holds the current directions. Safety prompts can involve reporting serious adverse events, disclosure to patients, patient safety organizations, peer review protections or how legal duties support a culture of safety. If the case names a state, look up that state's reporting statute; if not, explain the federal framework and note that states vary. Statutes go in APA legal citation format, and the paper is due on the date your section lists.
How this HCM 3080 Module 11 example is built
A sponge found eight weeks after emergency bowel surgery anchors the paper, with the mid-operation change of plan noted because it matters later. The reporting section cites the state law and explains that the duty belongs to the facility. The disclosure section describes the meeting itself, who attended, when it happened, what was said and how it was recorded. The protection section explains what the federal privilege for patient safety work covers and stresses that the chart and count sheet remain open to discovery. The learning section connects the root cause findings to research on risk factors and lists three process changes, and the conclusion links the legal duties to the module's theme.
Where the marks sit in the HCM 3080 Module 11 rubric
Safety papers are assessed on the distinction between reporting to a regulator and disclosing to the patient, on an accurate account of what patient safety privilege protects and what remains discoverable, and on a clear line from analysis to change. Mentors value research that explains why the event happened and recommendations that change processes rather than urging people to try harder. Citations to the state statute and the federal act should be exact. A description of disclosure as a planned conversation, with who, when and what, shows maturity. Organization within the expected length and APA legal style complete the grading. Explaining how protection of the analysis encourages candor connects law to safety culture, which mentors look for.
HCM 3080 Module 11 help: mistakes that cost marks
Safety papers sometimes stop at apologizing and retraining staff. Work through each legal duty in turn: reporting to the state, telling the patient and protecting the analysis. A common factual error is claiming that patient safety privilege hides the medical record; it shields the analysis, while the chart and count sheet stay discoverable. Describe disclosure concretely, naming who spoke, when and what was said. Use research to explain why the event happened, and make each recommendation a process change. Check your state's reporting statute if the scenario names one. The desk can prepare your safety assignment from the classroom directions and scenario. Name who owns each change.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Thomas Edison State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
More HCM 3080 and B.S. in Healthcare Management sample papers
- HCM 3080 Module 1: Law and Ethics Exercise
- HCM 3080 Module 2: Litigation Written Assignment
- HCM 3080 Module 3: Civil and Criminal Culpability
- HCM 3080 Module 4: Corporate Liability Assignment
- HCM 3080 Module 5: Chain of Command Discussion
- HCM 3080 Module 6: Informed Consent Assignment
- HCM 3080 Module 7: End-of-Life Decisions Discussion
- HCM 3080 Module 8: Workplace Law Exercise
- HCM 3080 Module 9: Records and Privacy Assignment
- HCM 3080 Module 10: Liability Insurance Exercise
- HCM 3080 Module 12: Legislation Final Project
- HCM 4040 Module 6: Final Project
- HCM 3530 Module 5: Asia-Pacific Systems Written Assignment
- HCM 3070 Module 2: Planning and Decision Paper
- HCM 4050 Module 2: Demand for Health Paper
HCM 3080 Module 11 questions, answered
Where can I find a free HCM 3080 Module 11 sample paper?
The complete safety written assignment is above, analyzing a retained sponge under state reporting law and federal patient safety privilege, with notes on each sheet.
Must New Jersey hospitals report serious adverse events?
Yes. The state's Patient Safety Act requires facilities to report serious preventable adverse events to the Department of Health and to inform the patient or family in a timely manner.
What does the Patient Safety and Quality Improvement Act protect?
Patient safety work product, such as analyses developed for reporting to a patient safety organization, which is privileged and confidential with limited exceptions. The underlying medical records are not protected.
What increases the risk of a retained surgical sponge?
Research found emergency surgery and unexpected changes in the procedure significantly increased risk, along with higher body mass index and missing counts.
Who should disclose an adverse event to a patient?
Usually the responsible clinician with a senior leader, in a private meeting that explains what happened, that it is being reviewed and what will change, documented in the record.