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

This is VAERS ID 1762284

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Case Details

VAERS ID: 1762284 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-10-04
Onset:2021-10-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 30155BA / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Interchange of vaccine products, No adverse event
SMQs:, Medication errors (broad)

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: NONE
Current Illness: NONE
Preexisting Conditions: DIABETES MELLITUS TYPE 2
Allergies: NONE
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Patient is an employee of the hospital and arrives to the vaccination area requesting to get the third dose PFIZER. Patient fills out the document. PFIZER vaccine is administered and when requesting the CDC card we realized that she had the first two doses of MODERNA. Patient reports not knowing that it was not PFIZER. We follow up by phone and she reports feeling good. Booster dose (third) PFIZER was administered to patient with MODERNA primary series without presenting adverse affects.


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