Age: 0.83
Sex: F
Vaccine: DTPPVHBHPB, DTPPVHBHPB
Symptoms: Extra dose administered
Clinical narrative: Patient seen in office for WCC with twin brother (Mom, Dad, Grandmother all present for visit). Vaccines ordered by Dr. (Vaxelis & PCV20) for both twins for their WCC's. Upon entry there was a discussion of what was easiest for the parents regarding vaccine admin & holding in laps or on the table. CCMA and RN were in room together and had each brought in a tray apiece. The trays were further away from RN as they were reviewing the vaccines. CCMA had grabbed the Vaxelis (which she was entered for) and RN grabbed for the PCV20 but grabbed from the siblings tray so she had the Vaxelis in her hand. Because they had already stated which vaccines they were administering, she didn't say it again. Upon administering the dose, they realized that both had given the vaxelis vaccine (we give vaccines with 2 people, both shots at the same time to decrease the time child is getting the vaccines). CCMA and RN stated they needed to get a provider and would be back. Parents immediately knew something had happened and felt scared and confused. Provider Dr. came in a few minutes later and communicated what they could based on the information from the CDC and listened to the parents concerns and questions. Parents stated they wanted to talk to someone in charge and wanted all documentation from the visit. As a site manager for multiple locations, I was not on the site of this location but was able to get here within 15 minutes. I immediately went in to talk with parents and apologize for their wait. Allowed them to express their fears and frustrations with me. Acknowledged what happened was not ok and this wasn't something anyone at clinic would take lightly. Informed them that over my time as a Pediatric Nurse I've experienced these situations more than once (not a norm, but also, I have experienced reviewing if this was ok for patients or not). Informed parents that I'm happy to get any information they may need and that studies show that for the most part, reactions are the same to a single administration as they are when multiple of the same vaccine are given. Informed them that a VAERS report would be completed and then sent their way to review. Informed them that provider Dr. would be calling this evening to follow up on how patient is doing and that I would be reaching out on Sunday to follow-up on the patient. Also discussed with parents that once further training for clinic as a whole was planned in light of this experience, I'd share that information with them. Patient was initially napping when I first arrived, but was awake and smiling before I left. No breathing changes. Legs did not appear red surround the administration sites. Did not palpate the area, but could see the legs when the grandmother turned her around. Child does have intrinsic eczema and had redness around her mouth that was from eczema. Otherwise, no color changes. Instructed parents that they will monitor her this evening and contact us with any concerns. Direct contact for myself given to mom so she can get through to me if she needs anything at all. While this is a very unfortunate event, parents verbalized understanding of the plan. Will continue to follow-up.