Age: 1.25
Sex: M
Vaccine: HEP
Symptoms: Extra dose administered, Injection site erythema, Injection site swelling, Pyrexia, Wrong product administered
Clinical narrative: On 6/28/23 @ 2:00pm patient was seen for a well child checkup and for 15 month immunizations (DTaP, Hib, PCV). I administered DTap, Hep B, and PCV. I incorrectly administered Hep B in the place of Hib vaccine. Vaccine information for Hep B was provided to the patient's father prior to administration of vaccines and consent was signed prior to administration. Father left before I was able to provide a copy of the updated immunization Record, father stop at the check-out desk and was provided a copy of the updated immunization record.  Patient's father called the clinic after leaving the clinic but I was not able to return the call the day of the receiving the message.  On 6/29/23 9:30 am while talking and reviewing previous day vaccines administered with Lead Pediatric Nurse I became aware that I incorrectly administered Hep B vaccine in the place of Hib vaccine. After becoming aware of the incorrect vaccine administered and incorrect lot number used the correct lot number was entered into charting system; the name of the vaccine administered was correct only the lot number was incorrect. Site Admin was also notified per myself of the incorrect vaccine administered and was instructed to enter an incident report, incident report entered. I then became aware that the patient's mother sent an email to LVN requesting a call back regarding the vaccines administered.   I then called the patient's mother @ 10:16 am: Spoke to patient's mother regarding DTaP, Heb B, and PCV vaccines administered. Patient's mother reported that patient did not have any unexpected reactions; mother reports patient had expected reactions of redness, swelling to injection site, and low grade fever that was controlled with Tylenol. Mother was informed that an incident report was completed per company policy. Patient's mother is requesting a copy of the incident report but I informed her I would pass the request to my supervisor. Mother states she" became aware of the incorrect vaccine administered when looking at the immunization system from my job". The vaccines entered into the system reflected the vaccines administered with the exception of the incorrect lot number used. Mother asked 'why the vaccine was administered after the alert from system". I explained to mother that an alert was never received, vaccines are entered into the clinic charting system and cross over to database, and an alert was never sent. Mother stated "that is not true because she works all day entering vaccines into database has the patient pulled up in database and is attempting to enter the same vaccine Heb B as being administered and the system will not allow it to be entered. Mother states the systems gives error of "duplicate vaccine". Mother stated she wants a call from the administration on my disciplinary actions and stated she is reporting me to the Board of Nursing.  I notified patient's provider of incident @ 11:00 am and that per patient's mother child did not have any adverse reactions. Provider stated verbal understanding.  Report Vaccine Administration Errors submitted via Practices through the Reporting Program. Per CDC recommendation Vaccine Adverse Events Reporting System (VAERS) submitted.   The vaccines administered and entered into the system included the follow: DTaP ;7yr<, 0.5 mL, 06/28/2023, Right Thigh, Y4259  Hepatitis B (historical) adolescent or pediatric, 0.5 mL, 06/28/2023, Right Thigh, 77X47 (This is the vaccine that the incorrect lot number was entered but not the incorrect vaccine administered) PCV 13 Prevnar 13, 0.5 mL, 06/28/2023, Left Thigh, FH9982