Gaps in the continuity of care and progress on patient safety.
This commentary discusses the concept of “gaps,” defined as discontinuities in care. The authors expand on the definition by explaining how complicated health systems produce multiple gaps between providers, organizations, and processes. The authors use two cases, which received significant media notoriety, to demonstrate how these gaps are analyzed. As an alternative to the usual focus on systems improvements for patient safety, the authors advocate a better understanding of how individuals handle gaps, particularly when they are created by new systems. Shifting attention to this model for patient safety interventions may offer new research opportunities and mechanisms for improved care.