Received Dec 26, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| DTAPIPV | DTAP + IPV (KINRIX) | GLAXOSMITHKLINE BIOLOGICALS | UNK | — | — |
| HEPA | HEP A (HAVRIX) | GLAXOSMITHKLINE BIOLOGICALS | UNK | — | — |
| HIBV | HIB (PEDVAXHIB) | MERCK & CO. INC. | UNK | — | — |
| PNC20 | PNEUMO (PREVNAR20) | PFIZER\WYETH | UNK | — | — |
Vaccines Due: DTaP, Hep A, Hib, Prevnar 20 Event Description: The patient presented for an 18-month well visit accompanied by parents and siblings. An RN retrieved vaccines from the refrigerator and verbally read them to a second RN, who cross-checked against the provider?s orders. Vaccines were prepared and administered. The RN retrieving vaccines unintentionally selected DTaP-IPV instead of DTaP alone, resulting in administration of an additional IPV dose. The error was not recognized at the time of administration. Discovery and Notification: The error was identified later, on 12/19 during vaccine reconciliation when the documented lot number did not match the DTaP product but corresponded to DTaP-IPV. The vaccine coordinator reviewed the discrepancy with involved RNs and notified the site manager. The patient?s provider was consulted on 12/23 and confirmed no clinical harm or intervention was required. On 12/23, the clinical supervisor and RN notified the patient?s mother by phone, explained the error, and provided reassurance. Outcome and Follow-Up: ? Extra IPV dose administered unintentionally ? Family notified once error confirmed, pt experiencing fever, fatigue and cough at time of call with mom. Pt had been experiencing side effects from vaccines and possible virus starting one day after well-visit. Pts siblings also had some of same symptoms, per mom. ? Incident reported internally Contributing Factors / Prevention ? Similar labeling/packaging of DTaP and DTaP-IPV ? Need for reinforced visual vial verification ? Review of vaccine storage and double-check procedures underway
NKA