Received Nov 18, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| UNK | VACCINE NOT SPECIFIED (OTHER) | UNKNOWN MANUFACTURER | N/A | UK318AB | IM / LL |
| UNK | VACCINE NOT SPECIFIED (OTHER) | UNKNOWN MANUFACTURER | N/A | UK318AB | IM / LL |
This RN became aware of this incident 11/18/25 involving MRN [withheld] afternoon after doing a daily check of respiratory vaccine inventory in both locations. This RN noticed that 2 doses of the same vaccine Beyfortus pediatric RSV (UK318AB, NDC 4928157515 exp 3/31/2026) were given to a patient within the same day. After speaking with [name withheld] RN she confirmed that this patient received 2 doses of the 50mg RSV IM in the LVL on 11/17. This vaccine was ordered by Dr.[name withheld]. [name withheld] RN explained that the provider originally ordered the 50mg patient but realized after administration that the patient's weight (11lb and 15oz) actually qualifies patient to receive 100mg dose instead. Another 50mg dose Beyfrotus was ordered by Dr. [name withheld] and given by nurse [name withheld]. No known side effects have occured following double administration of vaccine. Patient also received Vaxelis, Pneumococcol and Rotavirus in the same visit. No ED follow-ups noted in patient's chart. Upon realizing this 11/18 this RN escalated to nurse lead [name withheld] and DON [name withheld]. Then connected with [name withheld], RN from Sanofi to explain situation and advise on next steps. [name withheld] took doen this information for an internal safety report through Sanofi that will go to the FDA. Case Number: 02727803 [name withheld] stated that use of 2 doses of 50mg vaccine instead of the 100mg hasn't been studied so it's not recommended. The [withheld] Academy of Pediatrics discourages this use, because 50mg should be reserved for smaller infants who are at risk for worsening disease due to smaller airways. Providers should be aware that the insurers may not cover the cost of the 2nd vaccine because this hasn't been indicated. Sanofi recommended that we file a safety report with them regarding this patient. This RN to also file VAERS.
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cholecalciferol 10 mcg/ml, take 1 ML oral daily
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