WHY BIG MISTAKES HAPPEN: Raymond Rupert MD. MBA. Rupert Case Management Inc.

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A client purchased RCM’s Priority Call- extended healthcare benefits card online at


A team member at RCM reached out to the new client.

We got information from him about his health concerns and his needs.

It was clear from his current symptoms that he had a neuro-muscular disorder that had not yet been diagnosed.

He told us that on the previous day, he had had a  check up with his GP who did a physical, took his blood pressure and reviewed his labs. The GP told him that everything was normal.

We could not understand how the GP had missed the problem that we were able to see very clearly.

Mistakes relating to attention and knowledge do occur, as can be seen from this case study.

Having the knowledge is not enough for successful cognition in clinical settings. Specific attentional mechanisms such as cognitive fixation can prevent the right knowledge from being called to mind, even though in another context the doctor can be shown to possess knowledge about neuro-muscular disorders.

We are certain that this doctor knew about neuro-muscular disorders but within the context of the check up, he did not recognize the problem and his knowledge was not applied.

Cognitive work is about where to focus attention, how to deploy knowledge and how to deal with constraints in the organization in which work is carried out, for example, a busy practice.

The characteristic of cognitive fixation is that the immediate problem solving context can bias doctors in the wrong direction.

If the team has experience with complex problems, then even before they look at the patient’s data, they form expectations about what should happen next.

Cues that are present will draw attention. Expertise helps to direct attention before things happen.

Heuristics or cognitive rules of thumb are used to deal with complexity but are over simplifications. They make life easier and leave time for other work. Unfortunately, heuristics are distortions which lead to mistakes.

Conclusion: Centres of excellence focusing on complex disorders work differently. They are attentive to cues. They anticipate problems. They are able to mobilize knowledge based on experience. They take the time required to deliver better decisions.

That is why patient advocates should look for these centres of excellence when seeking solutions for their complex clients.

reference: Patient Safety, A Human Factors Approach, Sidney Dekker, CRC Press. 2011.