83 y.o. female with relevant past medical history of hypertension, hyperlipidemia and hypothyroidism presented to an OSH on 12/26 with complaint of significant lower extremity weakness. Pt was found to have AIDP, acute respiratory failure (extubated 1/5), and acute toxic metabolic encephalopathy, now s/p plasmapheresis (completed on 1/15) and cryoprecipitate (1/16) now presenting with incomplete tetraplegia with LE much more affected than UE. Admitted to for AIDP on 1/17/2025. AIDP -consistent with GBS, especially given elevated CSF protein, absent DTRs and recent influenza and COVID vaccines about 1 month ago -CSF studies to date reviewed: -Protein 124.6, glucose 101 -Lactic acid 2.2 -WBC 1, RBC 1 -Gram stain no organisms, Cx NGTD -VDRL not detected -VZV, HSV, CMV, WNV, enterovirus PCR negative -KOH prep reveals no mycelia or yeast forms; ABF smear negative -Cytology revealed increased white cells with a few neutrophils, lymphocytes and many monocytes -Completed 5 sessions of plasmapheresis last on 1/15.

Right side of mouth drooping

No adverse events – Dtap given to 7 year old patient instead of Tdap

MD ordered the wrong vaccine and it was administered to patient.

MD ordered the wrong vaccine and it was administered to patient.

Not an adverse event- just a duplicate shot- patient already received this shot in the past 11/19/2023

Adult Hep B dose administered to pediatric patient instead of pediatric dose. No treatment needed. Outcome N/A.

Pentacel was given by mistake instead of ActHib. 15 month series includes Dtap, Hib, Pneumoconjugate. Daptacel, Pentacel, and Prevnar-20 were given.

Patient was given a Pediactric dose of a Hepatitis A vaccine instead of the adult dose.

Death