Why It Matters
Pressure ulcer and medication bundles helped give a woman a new lease on life after being told she didn't have long to live.
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"She Got Her Fighting Spirit Back": The Power of Patient Safety Bundles

By IHI Multimedia Team | Friday, November 30, 2018
11-30 Blog photo

“Older people develop pressure ulcers.”

“Medication errors occur sometimes.”

“We’re dealing with humans, not automobiles.”

“These things happen.”

Do you recognize that kind of attitude? If you do, here’s some good news for you: You can avoid the “unavoidable.”


Ida Ottosen lived in Sønderjylland, a part of Denmark renowned for its bun and cake baking traditions. We met 86-year-old Ida to hear her explain how reliable care saved her life:

I haven’t baked in a year, so I’ve almost forgotten how to. But now I’m going to bake buns again using an old recipe. I’ve been too ill to bake. My back hurt and I couldn’t breathe. That’s how it started. Then I went to the hospital. I don’t really remember the circumstances. My husband and son were told I didn’t have many days left.

The local hospital has stopped treatment believing there was nothing more they could do. The family agreed to bring Ida home to die. They put her bed in the living room where Ida could spend her final days.

But Ida didn’t die quickly as the hospital had predicted. Coming home to her own bed, she was cared for by a community health care worker who used pressure ulcer and medicine safety bundles. The use of these patient safety protocols was the start of a complete transformation for Ida.

Zero Tolerance

In Denmark, implementation of safety bundles — including the pressure ulcer prevention bundle — has had a huge impact, both in hospitals and in community-based elder care. By using quality improvement methods and adopting “zero tolerance” for pressure injuries, many wards and units have succeeded in eliminating this kind of patient harm.

In community care, about 125 units — including nursing homes and home care units, covering over 12,000 elderly citizens — have introduced the pressure ulcer bundle. By November of 2018, 59 of these units had gone more than 100 days between newly acquired pressure injuries. In fact, patients in 30 units had not had a pressure ulcer in more than 300 days, the goal of the Danish Society for Patient Safety In Safe Hands program. The program is now ramping up for large-scale spread across all of Denmark.

This is in stark contrast to how it was in Denmark less than 20 years ago. Between 2002-2008, Danish hospitals reported that between 13 percent to 43 percent of patients had a pressure ulcer. These occurred despite hospital guidelines for the prevention of pressure ulcers. Pressure ulcers were considered an almost natural, unavoidable complication when patients were bed-ridden or immobile. Pressure ulcers were not even included as an adverse event or harm.

Reigniting the Will to Live

When the health care assistants and nurses first saw her lying in bed, Ida Ottosen had no appetite. She was pale and passive. Everyone assumed she was going to die within a matter of days. The pressure ulcer and medication bundles were put in place right away. Her health care providers predicted they could help Ida be safer and more comfortable, but they didn’t expect that — by reducing her risk of pressure ulcers and other harm — they had helped to reignite Ida’s will to live. From then on, her condition and outlook quickly improved.

Social and Health Care Assistant Grethe Reitz recalls, “When [Ida] got her fighting spirit back, we took the next step. Giving her a walker. Then giving her a kind of bike where she could sit down and exercise, building up her leg muscles.” Using the medication bundle, Reitz was able to dramatically reduce the amount and number of medications Ida was taking. Holding out her arms, Reitz demonstrates the size of Ida’s bag of medicine before implementation of the bundle. “It was enormous,” she explains.

A Happier Ending

Ida Ottosen passed away peacefully over a year after the hospital said she would die within a matter of days. During her extra days and months, she was happy and vigorous, able to enjoy life with her family and friends.

Ida is just one of many patients helped by the safe and reliable delivery of care that prevents harm. Yes, sometimes things unfortunately go wrong. But we must constantly and systematically try to prevent errors from happening. When we do, we can spare patients from unnecessary suffering from pressure ulcers or medication errors. Or maybe we can prevent some other malady which seems inevitable. What appeared unavoidable yesterday can be prevented tomorrow with the right care provided safely and reliably for every patient, every time.

Inge Kristensen is Chief Executive of the Danish Society for Patient Safety (DSPS) and Vibeke Rischel is the DSPS Deputy Chief Executive. The DSPS is a member of the IHI Health Improvement Alliance Europe.

You may also be interested in:

To watch a short video about Ida Ottosen, scroll to the bottom of this information about the Strategy of the Danish Society for Patient Safety.

The Great Impact of the Pressure Ulcer Bundle in Danish Health Care

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