Received May 4, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| DTAPIPVHIB | DTAP + IPV + HIB (PENTACEL) | SANOFI PASTEUR | 1 | UK346AA | IM / RL |
| PNC20 | PNEUMO (PREVNAR20) | PFIZER\WYETH | 2 | MM0530 | IM / LL |
| RV5 | ROTAVIRUS (ROTATEQ) | MERCK & CO. INC. | 2 | 2164395 | PO / MO |
On 04/16/2026 patient came in clinic for their 4 month check up. Provider PA-C, order Pentacel, Prevnar20, and Rotateq for infant. Medical assistant proceeded to draw up these vaccines. However, when drawing up Pentacel she only pulled the ActHib part of the vaccine from the fridge. She did not reconstitute vaccine correctly with the corresponding DtaP/IPV part of this vaccine. Medical assistant used a diluent meant for Merck live vaccines for reconstitution. After lotting vaccine into patient's chart she administered the vaccines. When unmatched number of vials were found in the fridge on 04/27/2026 by myself, vaccine coordinator, management was informed and we determined medical assistant was responsible. When she was asked about this, she admitted she was unaware that she was supposed to mix Pentacel's corresponding components. She states she did not see there was 2 different cap-colored vials. This is why she used different diluent. I contacted Sanofi to inquire about their recommendations and any reactions to look out for in the patient. They stated that ActHib was deactivated with the type of diluent used and we should revaccinate the patient as soon as possible if there were no adverse reactions. With manufacturer's recommendations and suggestions, medical assistant contacted patient's parents to inform of adverse event and inquire about any reactions after vaccination. ER visit and adverse reactions were denied by mother of child. Child was scheduled for revaccination.
No
No
None
Per mother of child, no known allergies.