Received Feb 20, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| MMRV | MEASLES + MUMPS + RUBELLA + VARICELLA (PROQUAD) | MERCK & CO. INC. | 2 | Z014407 | SC / LL |
Patient is a 1-year-old female who presented to the office on 02/02/2026 for her annual well-child examination. At the time of the visit, she was asymptomatic. Mother reported no concerns, and the patient was noted to be doing well. Last week on February 11th, staff member identified a vaccine storage error involving this patient. It was discovered that instead of administering the MMR vaccine, the patient received ProQuad, that had been improperly stored. The ProQuad vaccine had been mistakenly stored in the refrigerator rather than the freezer by the same medical assistant who later administered the vaccine. The medical assistant retrieved the vial from the refrigerator and administered ProQuad, Varivax and Hepatitis A during the visit. After the discovery, staff informed the office director, and he contacted the manufacturer (Merck) to report the temperature excursion incident and obtain guidance after finding out about the administration. The manufacturer confirmed that the ProQuad vaccine was improperly stored and outside of the frozen temperature range for an extended period of time. As a result, the vaccine was deemed invalid potentially resulting in insufficient protection against measles, mumps, and rubella. Independent review of storage guidelines confirmed that ProQuad must be stored frozen. Following the incident report, Attempts were made to contact the mother to assess for any adverse reactions since the administration of the vaccine. Initial calls were not returned, and a voicemail message was left. On 02/16/2026, contact was reattempted; a voicemail was left, and mother subsequently returned the call. She reported that patient has remained completely asymptomatic with no adverse reactions noted. The incident was explained in detail to the mother. She verbalized understanding that the improperly stored ProQuad is considered invalid and that patient will need to receive a valid MMR vaccine dose in one month. Mother agreed and stated she will call to schedule the appointment for revaccination. No adverse effects reported at this time. Follow-up pending scheduling of repeat MMR vaccination.
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