Received Jul 21, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| TDAP | TDAP (BOOSTRIX) | GLAXOSMITHKLINE BIOLOGICALS | UNK | H4279 | SC / OT |
On 07/15/2025, I was training my new vaccine on nurse visits we had this patient, in for a PPD placement and TDAP. picked both vaccines I checked them; in the pts chart it showed she received her last TDAP 2017. After we brought the pt back and confirmed DOB and name, we informed the patient that her last TDAP was 2017 and she would not be due till 2027, but if she had any recent injuries like a "dog bite or cut by a rusty nail" then she could receive it sooner. Patient verbalized that she wanted the PPD first and she would call to see if she needed a PPD for nursing school she expressed that she did have "some scratches recently". As the patient was thinking on the Administration we continued with the PPD. collected the syringe and needle while I spoke to the patient about nursing school. I looked down and noticed the syringe was the TDAP (Boostrix) and she administered this as a PPD in the right mid forearm totaling the amount to 0.5 ml . I advise the patient to wait in the room and we will be back i instructed to follow me. In the hallway i said "Do you notice what just happened?" responded "oh my gosh I'm so sorry". I advised her "It's okay, we are human we make mistakes, we are going to talk to a provider and figure out how to go about this". We went to the provider by the nurse's station which was NP and brought her to a room to discuss the situation. confirmed the patient received no harm, yes, a vaccine error but it will not provide immunity to the patient and to discuss with Dr on next steps for the next date for a TDAP. We then returned to the patient and informed her of the error. The patient gave me permission to administer her PPD in the left midforearm. I placed the PPD and documented in the chart. and I then discussed with the patient that the TDAP given will not be regiven today. Patient verbalized understanding and we instructed her this will not provide immunity for TDAP, the patient expressed no symptoms and encouraged to call us if she develops any pt verbalized understanding and agreed with the plan. documented the incident in her nurse's note. As well as was made aware. On 07/16/2025 I met with Dr informed him of the situation and he verbalized that the patient's father had texted him about the incident and wanted Dr to call her and discuss. Dr stated that he will contact the patient and discuss next steps with her. Dr stated "we don't offer Tdap sooner unless they are there for a new injury so she would not be due, that will not provide her immunity" I stated "Yes I understand, I should have not brought that in the room, definitely a learning moment for all". TDAP (Boostrix) NDC 58160-842-52 Lot H4279 Exp 08/30/2027 Manufacturer GSK
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