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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1759259

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Case Details

VAERS ID: 1759259 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-10-04
Onset:2021-10-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FC3183 / 4 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Extra dose administered, No adverse event
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: Parkinsons Disease
Allergies: Clindamycin, Hydrocodone, Penicillin
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Covid Clinic scheduled for residents at Home on 10/4/2021. Facility Director of Nursing took Public Health Staff room to room to administer vaccine. Director of Nursing had already completed the needed paper forms prior to clinic. This resident inadvertently received a fourth dose of the pfizer covid 19 vaccine and it was not discovered until entering data into the immunization registry. No adverse effects at this time. Physician notified of the incident.


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