1. What are consequences for patient and care?

• ▶ Severity (four-level scale)—intensity and cost of care

2. What is the complication's main determinant?

• ▶ Targeted disease/co-morbidity/surgery/treatment otherwise

3. In retrospect; could it have been avoided and how?

• ▶ By other treatment choice/execution/pre-care or after-care/…

  • ○ If so, then why was this not done?

    • ■ Because of pros and cons of alternatives/risk assessment/simply “wrong”

4. Prospectively: what is the lesson learnt?

• ▶ There is none; the complication is “all in the game”

  • ○ Then what was the risk?

5. Did the patient know, and how do we know he/she did?

• ▶ Yes, there is a “Lesson”!

  • ○ Then what precisely went wrong, and what should be corrected for the future, how, when and by whom?