Received Oct 6, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| HEPA | HEP A (HAVRIX) | GLAXOSMITHKLINE BIOLOGICALS | 1 | 3255P | IM / RA |
| MMR | MEASLES + MUMPS + RUBELLA (MMR II) | MERCK & CO. INC. | 4 | Y017527 | SC / LA |
What-EXTRANEOUS DOSE OF MMR GIVEN ON 10/02/2025 AT 8:56am. Why-(vaccine record received via e-mail 10/1/2025 2:58 pm to staff from staff at co. school was not keyed into databases at time of visit at 8:00am) RN FOLLOWED "TIPS TO PREVENT VACCINE ERRORS" PRIOR TO ADM. MMR ON 10/2/2025. SHE REPORTED TO SUPERVISOR SHE CHECKS COVER SCREEN, DATABASE PATIENT VACCINATION RECORD (OPTION #2), DATABASE I SCREEN, AND DETERMINED THAT PT'S MMR HISTORY WAS NOT CONSISTANT WITH SCHOOL ADMISSION. #1 MMR WAS GIVEN AT 8 MONTHS OF AGE, #2 MMR WAS GIVEN AT 14 MONTHS OF AGE, RN ALSO CHECKED STATE REPORT "FAILED NOT VALIDATED FOR THIS CATEGORY". RN ALSO HAD NS REVIEW VACCINE ASSESSMENT. VACCINES DUE AT THIS TIME HEP A, MMR, HPV, COVID-19, 2025-2025 FLU. RN ASK PT AND PT FATHER DID THEY HAVE ANY ADDITIONAL VACCINE RECORDS FROM ANY OTHER PROVIDER. FATHER REPORTED "NO" FATHER AND PT AGREED TO MMR, AND HEP A, DECLINED HPV AND FLU. COVID NOT IN STOCK. While working Triage Charts approx. 3:30 pm RN noticed an additional vaccine history for patient in the TRIAGE Rack at nursing station. She immediately notified her NS, which began an investigation on how this vaccine record that was stamped RECIEVED Oct.02,2025 showed up in Triage rack and not with pt chart during vaccine encounter. Staff was out of the office for the day at this time. Friday morning, NS, RN and staff met at nursing station to confirm "root cause" of this event. Staff reported staff from Co Guidance Office often e-mails her vaccine histories to review, key into databases, and then print a school vaccine certificate. Staff was in interviews and did not work on keying additional vaccines in system until later the next morning. 10/2/2025. MMR HX given 10/8/2023 was keyed in at 10:18:03 am, by that time pt had already received MMR 10/2/2025. RN DID NOT HAVE THIS ADDITIONAL VACCINE HISTORY DURING VACCINE ENCOUNTER, THEREFORE A VACCINE ERROR WAS MADE. ALSO THIS PT HAD 2 CHARTS, OR WHICH IS IN THE PROCESS OF BEING MERGED AFTER THE EVENT HAPPEN.
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