Age: 5.0
Sex: M
Vaccine: MMRV
Symptoms: Product storage error
Clinical narrative: No illness occurred; Improper storage of product in use; This spontaneous report was received from a pharmacist regarding a 5-year-old male patient. The patient's medical history included  scabies infestation. The patient's concurrent conditions were not reported. His concomitant medications included hepatitis a vaccine (HEPATITIS A) and diphtheria vaccine toxoid (+) pertussis vaccine acellular 3-component (+) polio vaccine inact 3v (vero) (+) tetanus vaccine toxoid (KINRIX). No known allergies.   A self-defrosting and self-calibrating freezer was used to store varicella virus vaccine live (OKA/MERCK) (VARIVAX) and measles, mumps, rubella and varicella (OKA-MERCK) virus vacc live (PROQUAD). On 02-MAR-2023 (Thursday), at 12:06pm, the nurse noted that the temperature display on the freezer in the pediatric unit was alarming. The temperatures were fluctuating, but were still within range. At that time, the temperature reading on the data logger was -18.32 degrees Celsius (conflicting information, also reported as temperature excursion did not occur as a result of a reading from a data logger). In the morning of an unspecified day in 2023, the temperature reading was found to be between -21.14 and -24.84 degrees Celsius. It was decided to proactively transfer the vaccines in a vaccine transport cooler to the hospital pharmacy across the street. The vaccines were removed at 12:15pm, with the temperature reading (of -30.98 degrees Centigrade), within range; and arrived at the hospital pharmacy within 5 minutes. Then, the vaccines were immediately stored in a pharmaceutical freezer unit that had a data logger. The freezer temperatures were monitored daily and were within range. On 16-MAR-2023, the vaccine for program reported that the vaccines in question were available and to be used within 3 months. The understanding was that the vaccines were viable (until 16-JUN-2023).  On 14-JUN-2023, the patient was vaccinated with an improperly stored dose of measles, mumps, rubella and varicella (oka-merck) virus vaccine live (PROQUAD) (rHA) subcutaneous injection, second dose, lot #W024971, expiration date: 05-FEB-2024 (also reported as 02-JUN-2023, conflicting information), administered subcutaneously in left thigh as prophylaxis (strength was not provided) (Product storage error). The suspect vaccine was removed from inventory and the vaccine was not resumed. It was reported that no illness occurred. The vaccine was available to return. The medication error occurred on administration. It was not prescribed any drug treatment for the experience.  This is one of severeal cases received from the same reporter.; Sender's Comments:  US-009507513-2306USA007830: US-009507513-2306USA007844: US-009507513-2306USA007881: US-009507513-2306USA007905: US-009507513-2306USA007917: US-009507513-2306USA008019: US-009507513-2306USA008071: US-009507513-2306USA008075: US-009507513-2306USA008077: US-009507513-2306USA008108: US-009507513-2306USA008171: US-009507513-2306USA008172: US-009507513-2306USA008267: US-009507513-2306USA008373: US-009507513-2306USA008388: US-009507513-2306USA008400: US-009507513-2306USA008402: US-009507513-2306USA008479: US-009507513-2306USA008487: US-009507513-2306USA008508: US-009507513-2306USA008515: US-009507513-2306USA008543: US-009507513-2306USA008567: US-009507513-2306USA008590: US-009507513-2306USA008606: US-009507513-2306USA008746: US-009507513-2306USA008749: US-009507513-2306USA008760: US-009507513-2306USA008772: US-009507513-2306USA008784: US-009507513-2306USA008835: US-009507513-2306USA008836: US-009507513-2306USA008843: US-009507513-2307USA000706: