Received Apr 8, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| DTAP | DTAP (DAPTACEL) | SANOFI PASTEUR | UNK | 4CA34C1 | SC / OT |
| HIBV | HIB (PEDVAXHIB) | MERCK & CO. INC. | UNK | Z007710 | SC / OT |
Vaccinations Hib PedVax and Dtap Daptacel were pulled out of vaccination refrigerator. Hib PedVax and Dtap Daptacel were drawn up with 1" needle. 1 needle was removed from Hib PedVax and Dtap Daptacel vaccinations and discarded from both vaccinations and placed in sharps container. New 1 needles were pulled from 1 needle container and placed on Hib PedVax and Dtap Daptacel vaccinations. Vaccinations were taken to patient's room and given. Hib PedVax was administered Left Vastus Lateralis then Dtap Daptacel was administered Right Vastus Lateralis, then Influenza vaccinations was going to be administered. Before Influenza vaccination was administered, I noticed needle size was 5/8" not 1". Hib PedVax and Dtap Daptacel needles were placed in the sharp s container. Asked MOC to wait with patient in the exam room with from interpreter ID. Influenza vaccination was taken back to locked med room. Immediately notified manager of the incident. 5/8" needle was removed from Influenza vaccination and replaced with 1" needle. Patient was given Influenza vaccination IM with 1" needle. Immediately verbally informed nurse manager of incident. Nurse manager verbally asked me to ask the provider if they want the vaccinations repeated. Verbally informed provider about incident and asked if she wanted me to repeat vaccinations. Provider asked me to ask, Regional Nurse Manager & Immunization & Infection Control Specialist. Zoom messaged Regional Nurse manager, no response, set up zoom video, no response, messaged again, no response. Verbally informed provider unable to get into contact with regional nurse manager. Provider verbally asked me to ask MAT, MPH. Zoom messaged MAT, MPH Hib PedVax and Dtap Daptacel were given sub-q. MAT, MPH said she is unable to provide information as it is for clinical setting, told me to inform DNP, APRN, FNP-C, FAAN, Chief Nursing Officer, and too look up information on ask the experts. Zoom messaged DNP, APRN, FNP-C, FAAN and informed her of the incident, no response. Zoom messaged manager that MAT, MPH asked me to talk to DNP, APRN, FNP-C, FAAN and I am waiting for DNP, APRN, FNP-C, FAAN to respond. Manager asked me if regional nurse manager responded and I said she didn t. Manager informed me to inform MOC what is occurring, the vaccinations were given with needle sizes smaller than they should have been and we will call MOC and let her know if patient needs to be revaccinated or if vaccinations are okay. I went into room with patient and MOC and explained the situation, vaccinations were given with needle size smaller than it should have been and I will call to inform you if patient needs to be revaccinated or not with assistance from interpreter ID. Received zoom message from MAT, MPH that she found the answer. Zoom message provider, ACIP states that if PCV, Hib, or DTaP is administered subcut, a provider has the discretion to repeat the dose(s) IM because there is no evidence related to immunogenicity of these vaccine administered subcut. There is no minimum interval between the invalid dose and the repeat dose. And asked if she wanted patient to be revaccinated. Sent zoom message to provider asking if she wanted the vaccinations to be repeated. Provider said no. Informed MOC with assistance from interpreter ID that patient does not need to be revaccinated. This occurred over 52 minutes. Patient was sleeping comfortably in MOC arms when I informed MOC he does not need to be revaccinated.
Esotropia of right eye
No
No
No
None