- Richard I Cook (firstname.lastname@example.org), associate directora,
- Marta Render, directorb,
- David D Woods, associate directorc
- a VA Patient Safety Center of Inquiry (GAPS), University of Chicago, Chicago, IL 60637, USA
- b VA Patient Safety Center of Inquiry (GAPS), Cincinnati, VAMC, Cincinnati, OH 45220, USA
- c VA Patient Safety Center of Inquiry (GAPS), Ohio State University, Columbus, OH 43210, USA
- Correspondence to: R I Cook, University of Chicago, 5841 S. Maryland Avenue, MC 4028, Chicago, IL 60637, USA
The patient safety movement includes a wide variety of approaches and views about how to characterise patient safety, study failure and success, and improve safety. Ultimately all these approaches make reference to the nature of technical work of practitioners at the “sharp end” in the complex, rapidly changing, intrinsically hazardous world of health care. 1 2 It is clear that a major activity of technical workers (physicians, nurses, technicians, pharmacists, and others) is coping with complexity and, in particular, coping with the gaps that complexity spawns.3 Exploration of gaps and the way practitioners anticipate, detect, and bridge them is a fruitful means of pursuing robust improvements in patient safety.
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
The notion of gaps is simple. Gaps are discontinuities in care. They may appear as losses of information or momentum or interruptions in delivery of care. In practice gaps rarely lead to overt failure. Rather, most gaps are anticipated, identified, and bridged andtheir consequences nullified by the technical work done at the sharp end. These gap driven activities are so intimately woven into the fabric of technical work that neither outsiders nor insiders recognise them as distinct from other technical work.
Gaps are most readily seen when they are aligned with organisational and institutionalboundaries that mark changes in responsibility or authority, different roles of professionals, or formal divisions of labour. For example, the loss of coherence in …