Age: 4.0
Sex: F
Vaccine: MMR, UNK, DTAPIPV, MMR
Symptoms: Cough, Gait disturbance, Injection site pain, Injection site reaction, Ocular hyperaemia
Clinical narrative: This visit to her PCP was our FIRST formal visit with this doctor and it was a new clinic (we previously came in March for nasal swabs and urine cultures as the clinic refused to see her and I had to work with the call line to get her in as she "wasn't established). The doctor discussed vaccines, and we communicated the summary from immunology and our wishes to space out her vaccines due to her condition, and to better check for reactions and verify what they were. The doctor suggested Kinrix, as it "combines DTap and Polio and is one less poke". We declined this and again stated we were not comfortable with this, and felt it was too much for her system at once for this good news of being cleared and no longer needing titers.  I was also not a fan of it being a newer vaccine, and I will add not a fan that the youngest age Kinrix can be administered is age 4 and her not being even 4 years 1 month yet. I also don?t like the neomycin and other antibiotic that was involved that could increase risk of reactions. She supported our choice, and we were told she ordered DTap and MMR as we requested. Later, a MA that wore a surgical mask came in and did not introduce herself and was very unfriendly. She also had her forehead covered, and she would be difficult for us to identify. Patient was very scared, so I was trying to hurry and pull up a video for her as the MA was not waiting and seemed to be in a rush. She did not smile and only said 10 or so words (Patient, yes, you need to restrain her arms, not like that!), and we are not sure I would be able to identify her voice. She did not ask two patient identifiers. We don?t recall seeing a badge as she had a traditional headdress, and Dr. did not state who would be administering her vaccines before she left. She even forcefully pushed my husband's right arm tightly over my daughter's as she required us to restrain her while she was sitting up. She was very rough with our daughter, who made her jerk quite a bit while giving what appeared to be a subcutaneous injection with a large yellow filled syringe that I didn't know was purposeful or not on her Left leg on my side. My daughter screamed so loud and this was a shock and she rarely reacts to vaccines for more than a second or two. The second injection was done in the right leg on my "husband's side". The MA did not say thank you, was not sympathetic, did not address my daughter, or us, and just left the room. We were not pleased and our daughter was still upset so we left the room. We did not see any other doctors, MAs, etc. and thought everyone left for the day as this was around 5:30 p.m. on a Friday. We walked out towards the door expecting to have to make our next appointment via phone. I saw a receptionist all the way at the end. Reception gave me a appt for next month for polio and varicella, BUT did not give me an after-visit summary, we were not asked about allergies before the injections, we did not receive a data, or pamphlets/information on the vaccines that she was given ( I did not realize any of this until the following day). On Saturday 22nd morning at 7:00a.m. she was not able to walk and expressed severe pain in her left leg pointing at the injection site. She insisted to be carried, and could only ice for 10 total minutes. After an hour she was still in pain, couldn?t walk, and was crying so I called the triage RN line (this office you cannot call directly despite them being open Saturday morning). I called to ask what vaccine was given in her left leg, as we were supposed to be leaving shortly for a wedding on the opposite side of the state and in case of emergency and hospitalization, I wanted to be able to report what vaccine it was. The RN thought I was joking when I said two vaccines were given, as she claimed only ONE was documented in the chart, MMR, and DTap specifically stated ?it was not administered?. She was not able to answer why this was, but prescribed Motrin 5mL to help which I had on hand. We left, and the doctor on call Dr. called an hour later. She was only told ?something about a vaccine? and did not have any additional information, and was going to call the MA at home. She called back an hour later and nonchalantly stated that Kinrix was given! I said ?what? and she was not able to answer any of my questions, and claimed it wasn?t relevant to ask if any errors were made, and that Dr. made an error, despite her already confirming Dr. ordered MMR and DTap previously. I asked her to contact immunology of their error, but instead all she told them is that Kinrix was given and what do they recommended. She then later told me she never spoke to them when she had, and did not make any notes in the chart she spoke to me any of the 3 times that I did, nor that she spoke to the MA. I think that she was protecting her. Unfortunately, the immunologists were not made aware of the error, and neither was the next on call physician the following day. On Sunday, June 23rd she also developed a rash that was red, warm to the touch, palpable, and approximately 2.5?x2.5? on her left thigh extending from the injection site. The on call stated it was from DTap reaction most likely (as we still were not sure which vaccine was placed where 100% or what vaccines they actually were). We were told not to worry and to draw lines to see if it grew. On Monday June 24th I got a call from Dr. who stated the MA was aware of her error on Friday, but only reported it to herself. The MA knew she was gone for the day and was ?not on? that weekend and claims to have left their required ?paper? that shows the child?s MRN sticker, vaccines with lot numbers, and verification for the paper and vaccines only signed off by a second MA. She had not seen the paper to confirm these vaccines were given, did not speak to anyone in the clinic to confirm the paper was there, did not speak to the MA in the office who was not there, and also was not in the office herself. Despite this, she told me she canceled her DTap order, and changed it to Kinrix. It was then charted as administered, and put into the data. I asked her not to do this until she confirmed the paper report for herself, but she already had done it and claims to have signed and made an addendum to her report of the error instead, and was their process. We discussed all of the various errors, intentional lies, mismanagement, etc. and she agreed with them. I spent the rest of the day on the phone and did not learn until later that Patient had developed a cough and red and swollen eyes. At this time, I also investigated the vaccines myself, and spoke to my husband about what we both saw on Friday. We determined ourselves that MMR was actually given in the left leg as it was yellow and was subcutaneous. This is NOT what we were told, nor how she was currently being managed, and so the new updates were shared with immunology and PCP call triage line around 2a.m on 6/25. On June 25th I communicated with the State Immunization Nurse Educator , who recommended I make a VAERS myself and contact that local health department. She did not like we did not receive any questions about allergies to vaccines that were administered, no pamphlets about the vaccines that were administered, no data updated form, no after visit summary or ANY documentation stating Patient received vaccines. The error was known that day, and we were not notified, nor they did they 100% admit the error to us after I repeatedly contacted them about adverse reactions. Nor did they identify the correct vaccine, nor location of the each vaccine (they stated the left was Kinrix and not MMR as the state confirmed based off the color and subcutaneous administration I saw). This is in addition to us specifically stating we did not want a vaccine, Kinrix, and it was given and was given without and order, and we had her immunologist?s support. I did afterwards on June 25th and spoke to staff at County Health Dept as staff suggested who actually manages this clinic and we talked for some time. She confirmed a lot of my concerns, and tried to help me piece together what happened to my daughter, which brought up more and more concerns and ?ways to cheat their system? that concerned us both. In addition to them not confirming what was actually given, and formally changing it in the State system. I then notified June 25th patient relations department for the second time with updates. They seemed not interested as staff mostly replied with ?mmhm? and did not seem to have a clear understanding of what exactly the problems were and was interested more in making assumptions about what the clinic did instead of looking for factual information. She stated they would NOT being reporting it to compliance, but the State told me it did need to be reported here as Patient has insurance and there are different regulations with the program. As of today, 6/26 I have still NOT been contacted by the clinic management team in regards to communications about this error. The PCP and MA were not in the office to verify the ?paper order?. This paper ?chart? of the vaccines, lot numbers, MRN, patient name, 2nd MA signature have not been confirmed it existed nor what it stated. It was also not confirmed a 2nd MA was even in the clinic Friday immediately prior to them being administered around 17:15-17:30 on Friday the 21st. Nor has anything been shown to us or the doctor tangibly that these were the vaccines my daughter got. Versus an MA?s memory who had not been at work in over 3 days before it was changed and documented, nor had to my knowledge, a second MA been spoken to, if one was utilized for their process. This process also does not include the 2nd MA verifying the order, which is not a 2-step verification. It has also not been confirmed what would have happened if she did not have these reactions, and we came back in July for Polio and Varicella as currently scheduled. It has been confirmed that appointment is not with a provider, and MA?s do not verify the data before administering vaccines for ?follow up? vaccine appointments. This means she likely would have been given Polio again in the same month, and would not have been potentially noticed at all, as the EMR would recognize the polio vaccine, and the data would recognize it as the correct Lot number. Currently, immunologist is stating no titers were needed at this time, however recognizing that the vaccines that were administered have not been confirmed. Assuming they will not be able to be confirmed if this ?paper? documentation that the Health Department requires is not found, they will have to give us perhaps different recommendations. Please help us.