Received Apr 1, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| DTAPHEPBIP | DTAP + HEPB + IPV (PEDIARIX) | GLAXOSMITHKLINE BIOLOGICALS | 1 | PE24L | IM / LL |
| DTAPIPVHIB | DTAP + IPV + HIB (PENTACEL) | SANOFI PASTEUR | 1 | UK107AA | IM / RL |
| PNC20 | PNEUMO (PREVNAR20) | PFIZER\WYETH | 1 | HH1326 | IM / LL |
Child presented to the health department for vaccines to be UTD per CDC catch-up schedule. Biological Father present with child & sibling. Children were extremely uncooperative & unruly during the entire visit. Father was in a rush to have visit completed by 2:30pm to make a phone call & to leave for another appt. at 4pm. Nurse felt rushed, nervous & frazzled in trying to get the children's vaccines prepared & administered. Both children were receiving the same vaccines during the visit. Nurse placed order of vaccines into the system & proceed to prepare the vaccines checking the vials of name of vaccines & expiration dates. As stated above, the nurse felt rushed by the father & failed to take the time to scan the vaccines prior to administration. Vaccines were administered & visit concluded. After the family had left the nurse began to scan the vaccines & document the required information & noticed that the wrong vaccine had been given. Child received Pentacel instead of the ActHIB vaccine. Nurse only focused on finding ActHIB on the vaccine vial & never noticed it being Pentacel. The child received 2 doses of DTap & IPV at day of visit. Nurse immediately notified her nursing supervisor & the Incident Report process began.
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NKA
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