Received Mar 3, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| MMRV | MEASLES + MUMPS + RUBELLA + VARICELLA (PROQUAD) | MERCK & CO. INC. | UNK | Y009347 | IM / RL |
Patient in clinic for 4 year wellness appt. Patient had Proquad and Quadracel vaccines ordered to be given. After vaccines given the nurse found vaccines were reconstituted incorrectly. Proquad vaccine was diluted with Quadracel vaccine and administered. Sterile Diluent was administered by itself to patient. Quadracel vaccine in clinic depending on stock (Private vs VFC) can be in pre-drawn syringe or vial. The pre-drawn syringe looks similar to sterile diluent that is to be used with Proquad reconstitution. Mother was with patient for visit and was informed by CTL that this error had occurred and RN would be in touch with her regarding if vaccinations needed to be repeated, what signs/symptoms to look for, etc. Mother voiced understanding. Child had no signs/symptoms of local reaction after vaccination. Waited in office 15 minutes. RN reached out to VFC coordinator to inquire about error and information regarding repeating. She reached out to the CDC help desk and per CDC both vaccinations will need to be repeated. The Proquad will need to wait to be repeated in 28 days. RN called and spoke with mother regarding this and explained the reasoning behind re-vaccination and a letter was written in regards to the error as mother was needing vaccinations for child to start preschool. Vaccine only appointment made for 28 days out for repeat vaccinations. Mother to call back before then with any further questions or concerns. Education was done with the nurse that administered and a new work flow for preparation of these vaccines was discussed to prevent this error in the future.