This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.
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.
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