Received Sep 3, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| JEV1 | JAPANESE ENCEPHALITIS (IXIARO) | INTERCELL AG | UNK | JEV23M11E | — |
Between the dates 7/24/25 and 8/13/25 there were twenty Japanese Encephalitis vaccine shots given with a pediatric dose (0.25ml) to adults. This medication error was discovered when a nurse was reviewing the preparation steps for the vaccine, and it was realized that the technician was following the preparation steps to administer a pediatric dose and not the adult dose. The (withheld) Health Agency was contacted for guidance on the steps forward. We were advised to have the members come back to the clinic to receive the adult dose in order to be properly protected. There were two major contributions to the error: 1. Manufacturer inserts only included pictures for pediatric dose preparation and so it was easy to overlook the fine print for adult administration. 2. There are no markings on the syringe to indicate what volume of the vaccine is being administered. The pediatric dose is indicated at the red line, but there is no way to actually confirm the amount of liquid in the syringe being given.