The nurses in Östhammar, a central Sweden school district, ended up injecting the boy with the cervical cancer jab during a mass drive to finish off the inoculation.
They were giving the third round of Gardasil to girls in grades six and seven, when pupils are 12-13 years old. As part of the same drive, they were finishing off their grade-six inoculation against measles, mumps and rubella (MMR), known in Sweden as the MPR vaccine (mässling, påssjuka, röda hund).
However, the boy ended up getting the cervical cancer jab by mistake when two nurses mixed up the receptacles holding the different types of injections.
The nurses almost immediately realized their mistakes, because the boy was second to last in the queue to get his jab, but the receptacle holding the MMR jabs still had two syringes waiting to be used when there was only one boy to go.
A senior nurse and the student welfare head later reported the incident to Sweden’s Health and Welfare Board (Socialstyrelsen), the national agency that investigates and follows up on misconduct and accident reports from the healthcare and care sectors in Sweden.
The inoculation drive meant the school district had drafted in an extra nurse to back up the staff nurses so they could work two and two, the report noted.
They also said that the boy’s family were told soon after of the mix-up, and that the boy showed no signs of any adverse reactions.
Following the incident, the district had also gone through and updated its work procedures to accord with the latest best-practice guidelines.