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This is VAERS ID 1745515

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First Appeared on 10/1/2021

VAERS ID: 1745515
VAERS Form:2
Age:86.0
Sex:Female
Location:Massachusetts
Vaccinated:2021-09-29
Onset:2021-09-29
Submitted:0000-00-00
Entered:2021-09-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 30135BA / 2 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: No adverse event, Interchange of vaccine products, Inappropriate schedule of product administration

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin D12, lisinopril, flipiZIDE ER 2.5mg ER
Current Illness: None known
Preexisting Conditions: Uncontrolled hypertension, non-compliance with medication regimen, Stage 1 Chronic Kidney Disease, hyperparathyriodism, uncontrolled Type 2 Diabetes with hyperglycemia
Allergies: NDKA
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Patient received Moderna mRNA vaccine on 6/17. She no-showed to her 2nd dose appointment on 7/15. After attempts to administer 2nd vaccine in clinic, plan developed to administer 2nd dose at her home. The writer of this incident requested a dose transfer from another Harbor site but neglected to indicate that the patient needed Moderna. Pfizer dose was dispensed to home care nurse, who gave it to the patient at 11:00am today (9/29). The patient was observed for 20 minutes by the nurse with no adverse symptoms.

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