Spikes in negative outcomes such as falls and pressure injuries during the pandemic were just some of the ways that COVID-19 revealed the failure of long-standing patient safety measures in eldercare and beyond, leaders from two federal health care agencies argue — while also challenging providers to think differently in the future. 

“We believe the pandemic and the breakdown it has caused present an opportunity and an obligation to reevaluate health care safety with an eye toward building a more resilient health care delivery system, capable not only of achieving safer routine care but also of maintaining high safety levels in times of crisis,” leaders from the Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control & Prevention (CDC) wrote in the New England Journal of Medicine.

The authors, led by former CMS Chief Medical Officer Lee Fleisher, cited CMS data showing that falls in skilled nursing facilities increased by 17.5% during the second quarter of 2020, with a 41.8% rise in pressure ulcers. The stress of the pandemic on so many other parts of day-to-day nursing home operations, the authors argue, led to a cascade of safety failures that extended far beyond COVID-19 infections and deaths. 

Those indicators “don’t bode well” for the future without bold action. 

“It is abundantly clear that the health care ecosystem cannot ask clinicians and staff to work harder, but must instead provide them with more tools and an environment built on a strong foundation of wellness and on instilling and rewarding a culture of safety,” the authors concluded.