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VAERS ID: 2057562

AGE: 15| SEX: M|State: ID

Description

Vaccine Administration Error: 15 yo male received incorrect formulation (5 -11 years of age formulation 0.2 ml (orange cap)) for second dose of Pfizer-BioNTech COVID-19 vaccine. Patient should have received adult Pfizer dose 0.3ml. Patient did NOT experience an adverse reaction.

Symptoms

Adverse reaction, Incorrect product formulation administered

Vaccines

VAX DATE: 27 December 2021 | ONSET DATE: 27 December 2021 | DAYS TO ONSET: 0
Vaccine TypeManufacturerVaccine NameDoseRouteSiteLot
  • COVID19
  • PFIZERBIONTECH
  • COVID19 (COVID19 (PFIZER-BIONTECH))
  • 2
  • IM
  • LA
  • FK5127

RECVDATE:21 January 2022
CAGE_YR:15
CAGE_MO:
RPT_DATE:
DIED:
DATEDIED:
L_THREAT:
ER_VISIT:
HOSPITAL:
HOSPDAYS:
X_STAY:
DISABLE:
RECOVD:
LAB_DATA:This is a Vaccine Administration Error report, patient did NOT experience an adverse reaction.
V_ADMINBY:PVT
OTHER_MEDS:None
CUR_ILL:
HISTORY:Migraine Headache without Aura Sleep Disorder
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:2
TODAYS_DATE:21 January 2022
BIRTH_DEFECT:
OFC_VISIT:
ER_ED_VISIT:
ALLERGIES:NKDA
V_FUNDBY:
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