Received Apr 8, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 4 | 3043000 | IM / RA |
On 4/3/25, I made an inadvertent error in administering a COVID-19 vaccine dose to a 17-year-old patient. This occurred while I was experiencing flu-like symptoms, including brain fog, which contributed to my lapse in focus. I deeply regret the mistake and wish to offer a detailed explanation of the circumstances that led to the error. Background and Circumstances: That day, I had already encountered confusion due to the handling of different vaccine lot numbers, which was compounded by the fact that I was also managing the administration for a different provider. While this situation should not have influenced my ability to properly assess the patient's eligibility, it led to a series of mental lapses that caused the mistake. I had been dealing with Flu A symptoms and brain fog, but I recognize this does not serve as an excuse for the oversight. It is important to note that at the time of administering the vaccine, I was operating on autopilot, which led to an error in selecting the appropriate vaccine dosage for the patient. The dose administered was intended for a different age group (6 months to 11 years), which does not align with the recommended dosage for a 17-year-old. Immediate Actions Taken: As soon as I became aware of the mistake, I immediately reported the adverse event according to the protocol. I take full responsibility for the oversight and acted quickly to ensure that the situation was handled appropriately. I deeply regret the error and the potential implications it may have had on the patient's health and wellbeing. I am committed to improving my processes to ensure such an oversight does not occur again in the future. This includes taking additional steps to review vaccine guidelines and ensuring greater focus on patient eligibility criteria, especially during periods when I am unwell. Moving Forward: I will take steps to reinforce the importance of accuracy and vigilance in vaccine administration, especially during times of personal health challenges. I understand the gravity of this incident and am actively working to minimize any future risks to patients. I would like to reassure all involved parties that this event was promptly reported and fully acknowledged, and I am committed to ensuring the safety and well-being of those I serve.
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