Age: 80.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Circumstance or information capable of leading to medication error, Incorrect dose administered, No adverse event
Clinical narrative: No adverse events to report, Writer is reporting 2 vaccine administration errors 1) Vaccine administration error 11/02/2021, Moderna booster (50 mcg/0.25 ml) dose administered as 3rd COVID-19 vaccine dose, Patient was immunocompromised at that time and should have received Moderna 3rd dose primary series (100 mcg/0.5 ml) dose on 11/02/2021 and not Moderna booster dose (50 mcg/0.25 ml). This error was not realized until 8/19/2022 when Writer spoke with PharmD, and it was determined documentation in database was incorrect. PharmD advised per records Patient actually received Moderna booster (Description): (50 mcg/0.25 ml) dose on 11/02/2021. PharmD also reviewed patient's pre-vaccination paperwork and no documentation on pre-vaccination paperwork regarding immunocompromised status with that section "blank." PharmD advised on 11/02/2021 vaccination clinic only was administering "booster" vaccines and not primary dose vaccines that day. PharmD reports she was aware that there has been a problem with documentation not accurately reflecting Moderna vaccine booster doses (50 mcg/0.25 ml) and instead documentation indicates patients have received Moderna 100 mcg/0.5 ml (primary series dose). PharmD is aware her pharmacy has previously communicated to database about this problem. On 8/19/22 Writer was informed by PharmD that she manually edited Patient documentation in database after Writer's conversation with her to accurately reflect that patient received the Moderna booster dose (50 mcg/0.25 ml) on 11/02/2021.  2) Vaccine administrative error 08/16/2022, Moderna booster dose (50 mcg/0.25 ml) was administered as 4th COVID-19 dose, when Patient should have received 3rd Primary dose series (100 mcg/0.5 ml) instead as is immunocompromised and meets criteria for 5 dose Moderna series per Rheumatologist. This error was not realized until 8/19/2022 when Writer spoke with PharmD and it was determined Patient's previous documentation in database from COVID-19 vaccine date of 11/02/2021 was incorrect (database indicated Patient received 3rd Primary dose series on 11/02/2021 (100 mcg/0.5 ml dose), instead of actual dose Patient received of Moderna booster dose of 50 mcg/0.25 ml. PharmD advised per records Patient actually received Moderna booster (50 mcg/0.25 ml) dose on 11/02/2021. On 8/19/2022 Writer was informed by PharmD that she manually edited Patient documentation in database after Writer's conversation with her to accurately reflect that Patient received the Moderna booster dose (50 mcg/0.25 ml) on 11/02/2021. Writer updated on 8/19/2022 directly after Writer's phone conversation with PharmD on 8/19/2022 regarding patient situation and Dr. advised Writer she would complete VAERS report on this patient 8/19/22. Writer updated Patient of situation on 8/19/22 and advised next step for patient was to schedule another vaccine appointment to receive appropriate 3rd primary series dose (100 mcg/0.5 ml) as next step as Writer's Moderna booster was considered invalid on 8/16/22 (underdose) per Dr. communication with Health Pharmacy on 08/19/2022. Writer contacted via phone at  VAERS on 8/23/22 to confirm report was made by Dr. on 8/19/22 and verified it was submitted by Dr. on 8/19/22 per her report. However, employee from VAERS notified Writer today that Lot numbers for all COVID-19 vaccines for patient should be included and therefore Writer is submitting a separte VAERS report today with that information and potentially more detailed information. Patients COVID-19 vaccinations: 01/14/2021-Primary series dose Moderna (100 mcg/0.5 ml) Lot#037K20A/Dose 1 02/11/2021-Primary series dose (100mcg/0.5ml) Lot#041L20A/Dose 2 11/02/2021-Moderna booster dose (50 mcg/0.25 ml) Lot#076C21A administered -incorrect dose-should have received 3rd Primary series dose(see details above) 08/16/2022-Moderna booster dose (50mcg/0/25 ml) Lote#052B22A administered-incorrect dose-should have received 3rd dose Primary series dose as had received Moderna booster dose (50 mcg/0.25 ml) on 11/02/2021 (see details above)