TG 167 Attachment A: Sentinel Event Report Form

Date Received: 21-July-2014

Log Number: 14-24-CS

Logged By: P. Shaffer, RN

TO BE COMPLETED BY THE SENTINEL EVENT REPORTER

Volunteer ID:

Date(s) of Sentinel Events: 14-July-2014

Country of Service:

Country of Sentinel Event:

Event (Check all that apply)

Unexpected adverse health related occurrence that could have resulted in or has
resulted in a Peace Corps Volunteer or Returned Peace Corps Volunteer long-
term morbidity or disability.

PCV/T PCRV RPCV

OR:

PCV death during service

OR:

RPCV death probably related to service

Effective 3/2011, Last Update 12/2011

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 TG 167 Attachment A: Sentinel Event Report Form

Description of event(s):

7/14/14: PCT under observation with anaphylactic reaction to peanuts. Sxs: SOB, vomitting - administered Epi-Pen
currently stable BP 92/58.
Major concern: PCT had 50 mg Diphenhydramine in his system 90 minutes prior to ingestion of food but he still
had a full blown anaphylactic reaction. Peanuts are ubiquitous in diet. Host family extensively counseled
not to put peanuts in PCT's food - that message was not enough.
7/14:14: RMO questions if accommodates a peanut allergy.
7/21/14: See attached Timeline.

CORRECTIONS TO PRESENTING PROBLEM:

Pre-Service - Dr. Simon has decided for anyone with a history of life-threatening allergic reaction the protocol will
be that applicant be placed in MAC cue. The Asthma MAC protocol is as follows: 24/7 ER with oxygen, pulse ox,
Albuterol in MDI and preferable nebulized solution, IV fluids, availability of PO and parenteral steroids, CXR, within
4-6 hours of the site.

Additonally, this medical issue will get incorporated into a new screening guidelines which will be called -
"Airway Support".

10/1/14 - Sentinel Committee reviewed submitted documentation and found logic in MaXx needed to be
changed to trigger an automatic MAC for PCV with Severe Allergies. Implemented 10/1/14 with Pre-Screening
Staff Training. CASE CLOSED

Name of Reporter and Title: Patricia Shaffer, RN QI

Date: Oct 1, 2014

Effective 3/2011, Last Update 12/2011 Print Form

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