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 | — | — |
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, mom stated at time of call that all 3 kids had cough, patient was experiencing side effects of either vaccines and/or virus. ? Incident reported internally and to the state 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