Adverse Event Reporting

VAERS ID 903236
Gender Unknown
StateCode AL
Pharmaceutical Company PFIZER\BIONTECH
Lot Number EK5730
Number of vaccinations 1
Vaccinated 2020-12-16
Onset 2020-12-16
  • Product preparation error

Current Illness


Preexisting Conditions


Other Medications


Previous Vaccinations



Laboratory Data

None to date


Pharmacist was diluting doses of vaccine for vaccination clinic in hospital.
After dilution of 3 vials, the compounding pharmacist passed off to the on coming pharmacist.
The on coming pharmacist grabbed one of the empty vials of vaccine and added diluent to the empty vial.
6 doses were drawn up and delivered to the vaccine clinic with only diluent in the syringe.
The pharmacist in the clinic noted the number of syringe doses exceeded the number possible from the amount of vials used and sequestered all vaccine doses in clinic.
It is possible some of the patients in the first hour received diluent instead of vaccine but is not known for certain.
The pharmacist at the clinic kept the record of all the patients in the morning clinic.
Would you recommend any actions prior to the second dose for these patients? Is there any utility in antibody testing the identified patients prior to administering the second dose? Have parameters been established for titter? Please provide direction.