A 23-year-old patient received the Pfizer-BioNTech COVID-19 vaccine instead of the flu vaccine. Afterwards, the patient was asked when she had received the first two COVID-19 vaccines, and the error was recognized. While the vaccine provider disclosed the error and apologized to the patient, the patient’s request to get a flu vaccine was crossed out and replaced with “COVID (3rd)” in the documentation provided to the patient.
A 17-year-old visited a community pharmacy for a flu vaccine and was given a COVID-19 vaccine in error. The patient was called that evening and the error was disclosed; however, the patient’s parents were upset because they were opposed to the COVID-19 vaccine.
A 26-year-old made an appointment at a local pharmacy for the flu vaccine. Upon arrival, the patient was given a screening form, consent form, and a Vaccine Information Statement (VIS) for the flu vaccine. However, a COVID-19 vaccine was administered in error. The error was immediately discovered, and the patient was given the flu vaccine. However, the pharmacy did not provide the patient with a record of the third COVID-19 vaccine.
A mother, son (10 years old), and daughter (6 years old) received the Moderna COVID-19 vaccine instead of the flu vaccine. When the mother experienced symptoms similar to those she experienced after receiving the Moderna COVID-19 vaccines, she called the pharmacist. After watching a video of the vaccination clinic, the pharmacist called the mother to report that she had received the Moderna COVID-19 vaccine in error, but her children had received the flu vaccine. After her daughter developed a local reaction at the vaccination site, the mother called the pharmacist and asked him to watch the video again. A few days later, the pharmacist called the mother to say that both of her children had also received the COVID-19 vaccine instead of the flu vaccine.
A vaccinated 70-year-old patient received the Pfizer-BioNTech COVID-19 vaccine instead of the flu vaccine. He completed a consent form for the flu vaccine, but was told after administration that he now had his “COVID-19 booster.” He was then also given the flu vaccine and asked to provide consent for the COVID-19 vaccine he had received in error.
A 4-year-old child received the Pfizer-BioNTech COVID-19 vaccine instead of the flu vaccine. The Pfizer-BioNTech COVID-19 vaccine is not approved for EUA in a 4-year-old child. While the FDA is currently reviewing data submitted by Pfizer-BioNTech from a COVID-19 vaccine study in children 5-11, the dose is much smaller than that used for patients 12 years and older. Fortunately, the child suffered no ill effects from the vaccine.
A 22-year-old patient was scheduled to receive his first COVID-19 vaccine dose. The vaccinator assumed the patient was there to receive the flu vaccine and administered that instead. About 20 minutes after the patient left the pharmacy, he received a call informing him about the error. It is unclear if the patient returned to the pharmacy to receive the COVID-19 vaccine.
A 21-year-old patient was scheduled to receive a COVID-19 vaccine but was given the flu vaccine instead. Before the error was recognized, the patient had been given a COVID-19 vaccination card. The patient later noticed that the forms she had received from the pharmacy suggested that she had received the flu vaccine. She returned to the pharmacy, where the error was confirmed. The patient received her COVID-19 vaccine but no apology for the error.
A patient, who happened to be a pharmacist, scheduled an appointment at a local pharmacy to receive the flu vaccine, and his wife scheduled an appointment at the same time to receive both the flu vaccine and the Pfizer-BioNTech COVID-19 booster. Because there was a high-volume of patients receiving the COVID-19 booster, the pharmacist asked the vaccine provider to double check that he was only getting the flu vaccine (he had previously received a series of two Moderna COVID-19 vaccines, for which a booster has not yet been approved for EUA). After the vaccine provider confirmed that he was administering the flu vaccine, he grabbed the wrong syringe and gave the patient the Pfizer-BioNTech COVID-19 vaccine booster in error.