Received Sep 24, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | N/A | 3052579 | IM / RA |
There were no adverse events, but the incorrect vaccine was given. We had received the pediatric (6 months to 11 years) doses of Moderna Spikevax earlier that day and the tech that unpacked them didn't realize they were pediatric shots, so she didn't label them as such and put the bag of syringes next to the adult doses of Spikevax. The syringes of peds Spikevax DO NOT say pediatric or 6m-11y or anything to distinguish that they are for kids. The only difference is the syringe shows 0.25ml instead of 0.5ml. The lot number of the adult 0.5ml dose that we were using was 3052549 (exp 5/8/26) and the lot number of the 0.25ml dose that we accidentally gave was 3052579 (exp 5/10/26). As you can see, the lot numbers were off by only one number, so we thought it was just a typo on our end. Again, the sticker that comes off the syringe DOES NOT say 0.25ml or peds dose or anything to distinguish it from the adult dose. We realized what had happened the next day when another pharmacist (who had seen the peds syringes at a different pharmacy) noticed the syringe was a pediatric dose. We went back and checked our shots given, and this was the only one that we found was done in error. The patient has been contacted and we are going to give her one more 0.25ml dose to bring her up to the full dose of 0.5ml.
none
none