Gaps in the continuity of care and progress on patient safety

Abstract

Complex systems involve many gaps between people, stages, and processes. Analysis of accidents usually reveals the presence of many gaps, yet only rarely do gaps produce accidents. Safety is increased by understanding and reinforcing practitioners' normal ability to bridge gaps. This view contradicts the normal view that systems need to be isolated from the unreliable human element. We know little about how practitioners identify and bridge new gaps that occur when systems change.