Tracking the cause

A nurse’s follow-up discovered a potentially life-threatening problem and changed the way MedPaks are labeled.

Karen Dillon, RN, R-BC, was trying to pinpoint the cause of an elderly patient being re-admitted to the hospital when she discovered a potentially life-threatening problem.

The patient was diagnosed with congestive heart failure, which occurs when the heart doesn’t efficiently pump oxygen-rich blood to the rest of the body. It can cause shortness of breath and excess fluid retention in the body, which then, in turn, causes the heart to work harder to get its job done. Patients with heart failure often are prescribed diuretics, or “water pills,” which are medications that reduce the level of fluid.

“We were going through his list of medications,” Dillon recalls. “I asked about one medication and he told me, ‘Oh no, I’m not supposed to be taking that.’ In fact, it was a critically needed diuretic that probably would have prevented him from being readmitted if he was taking it regularly.”

New labeling

Karen Dillon, a board-certified registered nurse and Accountable Care Organization case manager, checks in with patients after hospital discharge to ensure they receive the care they need and comply with ongoing doctor’s orders.

During the course of her conversation, Dillon discovered that the patient had not taken the diuretic for more than a week and, in fact, had rapidly gained almost 20 pounds and had difficulty breathing just prior to going to the emergency room. She also found that the patient had taken advantage of an easier way to remember taking several medications — he had signed up for MedPak, which provides bundled medications in cellophane packages.

The problem, though, was that the MedPak didn’t have the prescribed diuretic inside because it was a new prescription. Instead, it was provided in a separate pill bottle. The patient had forgotten about the bottle and assumed all his medications were in the bundled packs.

“A little misunderstanding can end up being huge in a patient’s care and in their overall health,” says Dillon, a board-certified registered nurse and Accountable Care Organization (ACO) case manager. “It was really scary to see how this problem impacted the health of this patient.”

Dillon immediately alerted the pharmacy about the issue. Now, thanks to her initial detective work and brainstorming with pharmacists, each individual MedPak is clearly labeled on the outside if there are additional medications that must be taken.

Preventing readmissions

Dillon is one of three full-time ACO care coordinators who track and check in with patients after hospital discharge. The team has up to 40,000 patients in their database. Most are healthy and don’t require much support, but others require time, dedication, and compassion to ensure they receive the care they need and comply with ongoing doctor’s orders.

“People can be so vulnerable and overwhelmed when they are ill,” she says. “They need to have someone to advocate for them and help them stay as healthy as possible. We all try to make a difference with each and every patient we touch.”

For this particular patient, Dillon became more than a care coordinator, she became a friendly point of contact for additional health care support.

“He said it made him feel less alone in handling all of the issues,” she adds. “That really warmed my heart to hear that.”


  1. Nice work, Karen. The CHF meds can be so confusing to patients… Way to have a huge impact on the care of many.

  2. Karen, your thoughtfulness and investigation of the matter is great example to us all to help prevent future errors and adverse events- thank you!

  3. Wonderful story, Karen! Just that little bit of oversight makes a mountain of difference. It’s still true: an ounce of prevention is worth a pound of cure.

  4. Way to make a difference, Karen! Patients who are connected to ACO case managers, are so fortunate in many ways! Keep up the great work!

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