Bridging Gaps: How Safety is Created and Broken

Healthcare is an increasingly complex system with many inherent hazards, tradeoffs and vulnerabilities to failure. People perceive these hazards and adapt individually, in groups, and organizationally to avoid or guard against them in the pursuit of their goals. These efforts "make safety." A critical part of this process is feedback on how these adaptations are working or about how the environment is changing. Recognizing the limits to or the vulnerabilities of this system shows us where failures may occur and can guide investments to cope with these paths toward failure.

Accidents occur because conditions overwhelm or nullify the mechanisms practitioners normally use to detect and bridge gaps. Increasing safety is accomplished primarily by understanding and reinforcing practitioners' ability to detect and bridge gaps.

Thus, practitioners and the system that supports their work in context actually are the means by which patient safety is created and sustained. It is the technical work of physicians, nurses, pharmacists, and technologists that confronts inherent hazards and threats to safety. They are the ones who face the dilemmas and conflicts of practice; they are the ones who receive the demands for production and cope with the complexity of the real world; they are the ones who bridge the gaps that modern healthcare produces.

The GAPS Center studies how practice is organized to allow practitioners to create success in the face of threats, given a backdrop of organizational and technological change.

To learn more about the role gaps play in healthcare you can read:
     A Brief Look at GAPS (pdf) 
     Gaps in the Continuity of Care and Progress on Patient Safety (pdf)

If you are not able to view a PDF, you can download the necessary Adobe Acrobat Reader.

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