1. What were the system failures in Dorothy Johnson's care? 

2. What is the physician's responsibility to follow up with a patient, and how do you think the reality differs from the ideal? What can healthcare professionals do to make the follow-up process go more smoothly? 

3. According to her daughters, even though Mrs. Johnson consented to the ERCP procedure, she did not know or did not understand that the doctor was going to perform a sphincterotomy. In Mrs. Johnson's case, the sphincterotomy was a nonemergency elective procedure. What does this say about the informed consent process in this case, and how do you think it could have been handled differently? 

4. How do you think the problem of overuse of procedures such as ERCP can be addressed? 

5. What should healthcare professionals do to communicate with patients following an adverse event? How can hospitals and clinics ensure that there is learning from these events? 

6. What can we learn from this case about designing strategies to improve communication with patients and families who are undergoing a medical emergency? 

7. Which of the core competencies for health professions are most relevant for this case? Why?