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JAMA. 2004;292:1171.

	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

MMWR. 2004;53:662-664

CDC and the Food and Drug Administration (FDA) have been notified about the potential for inadvertent administration of tetanus toxoid–containing vaccines (TTCVs) instead of tuberculin purified protein derivative (PPD) (Tubersol®, Aventis-Pasteur, Swiftwater, Pennsylvania; Aplisol®, Parkedale Pharmaceuticals, Rochester, Michigan) used for tuberculosis skin tests (TSTs). The Vaccine Adverse Event Reporting System (VAERS), a passive surveillance system jointly operated by CDC and FDA,¹ detected clusters of medication errors in at least two states. These findings, along with another previously reported investigation involving the same error,² suggest the need for health-care providers to take additional steps to minimize the risk for inadvertent intradermal injections of TTCVs.

In April 2004, five reports of medication error involving tetanus toxoid (TT) from a health-care provider were identified. Patients were vaccinated on three different dates; all experienced local reactions without complications. Another cluster reported to VAERS in June 2003 involved an undisclosed number of patients; . . . [Full Text of this Article]