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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1695046

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Case Details

VAERS ID: 1695046 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-09-10
Onset:2021-09-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 058E21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Extra dose administered, Interchange of vaccine products
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: Calcitonin 200IU nasal spray, ciprofloxacin 250mg
Current Illness: UTI
Preexisting Conditions: chronic recurring uti and genitourinary disease
Allergies: macrolides and ketolides
Diagnostic Lab Data: na
CDC Split Type:

Write-up: The patient was mistakenly administered the covid (Moderna) vaccine. She had 2 doses of covid (Pfizer) vaccine, previously. She got both FluzoneHD and the covid (Moderna) vaccine on 9/10/21.


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