VAERS ID: 1861653

AGE: 8| SEX: F|STATE: CA (United States)

Description

At 2:45pm on 11/11/21, patient received the Pfizer-BioNTech Covid-19 vaccine 12-17 years formulation (purple cap) INSTEAD OF the Pfizer-BioNTech Covid-19 vaccine 5-11 years formulation (orange cap). Patient was observed in the office for 15 minutes without adverse reactions and was taken home by her mother. The on call pediatric Infectious Disease physician was paged by Dr. Dr called the family to inform them of the event and for reassurance and education on symptoms. Facility will monitor patient closely.

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Symptoms

Incorrect dose administered, No adverse event

Vaccines

VAX DATE: 11-11-2021| ONSET DATE: 11-11-2021| DAYS TO ONSET: 0
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (PFIZER-BIONTECH)) 1 COVID19 PFIZER\BIONTECH EW0187 IM LA

RECVDATE:11-11-2021
RPT_DATE:
CAGE_YR:8
CAGE_MO:
DIED:U
DATEDIED:
L_THREAT:U
ER_VISIT:
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:U
LAB_DATA:
V_ADMINBY:PVT
OTHER_MEDS:Zyrtec (cetirizine) 10mg daily
CUR_ILL:
HISTORY:Idiopathic Chronic Urticaria
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:
TODAYS_DATE:11-11-2021
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:
V_FUNDBY:

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