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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1330975



Case Details

VAERS ID: 1330975 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Male  
Location: New York  
Vaccinated:2005-06-02
Onset:2021-05-19
   Days after vaccination:5830
Submitted: 0000-00-00
Entered: 2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0183 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: Upper respitory infection
Preexisting Conditions: N/a
Allergies: Shell Fish
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: When administering the vaccine the needles detached from the syringe causing the vaccine to not enter the patient.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1330975


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