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