Received Feb 3, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| HIBV | HIB (ACTHIB) | SANOFI PASTEUR | 4 | UK363AA | IM / LL |
On 01/30/2026, pt came to Public Health Center Clinic for vaccination. PHN, prepared and administered a dose of ActHIB Lot #UK363AA Exp. date 12/2026 and reconstituted it with 1.0 mL sterile saline from a pre-filled syringe rather than the provided diluent and administered to the patient in the (Left Vastus laterals). The patient also received four other vaccinations. PHN observed and assisted. On 02/02/2026 at 10:30am the discrepancy was identified by Staff RN who notified PHN Supervisor at 2:15pm. PHN Supervisor, contacted the child?s mother during a follow-up call. The mother reported the child was doing well, with no reported symptoms and no fever. The mother was informed that she would be contacted if the child needed to return to the clinic for re-vaccination. The mother was not informed about the error at this time due to further instruction by provider. PHN, informed Manager, of the incident at 4:30pm, 8:48am, . Dr was contact at 5:00pm by phone and told of use of sterile water instead of diluent in a medical consult, no orders received. The medical consult was also requested by email. Dr confirmed receipt of email and gave no new orders. On 02/03/2026 , Dr emailed back stating that "Unfortunately for Act-HiB sterile water might render the vaccine inert". PHN Supervisor acknowledged and informed a call will be made out to mother to re-vaccinate. Dr replied by email, "thank you". preventive measures will be taken into place. There was no Adverse event for this case.
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