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1 病例介绍 1996年8月5日下午3时左右,一3个月婴儿,体重6.5kg,在我区某医院注射百白破疫苗第一针。护士未按接种规程操作,事先即用相同规格、相同颜色的两支注射器分别吸取卡介苗和百白破疫苗各0.5ml,并将两支注射器放置在同一冷藏包中。接种时,误将装有卡介苗的注射器当作装的百白破,给该婴儿上臂三角肌肌内注射0.5 ml。当天察觉误种后,立即找到该婴儿,留院察看,同时逐级报告上级主管部门。该婴儿8月3日曾感冒发烧,经药物治疗后好转。误种后,次日凌晨3时许,体温39.1℃。原有发烧、咳嗽等症状加重,并出现短暂性呼吸困难。注射部位深部可触及直径1cm～2cm的结节。医院
1 Case description At about 3 pm on August 5, 1996, a 3-month-old baby, weighing 6.5kg, was injected with the first dose of Baitai broken vaccine in a hospital in our district. Nurses do not follow vaccination procedures, that is, with the same specifications beforehand, two syringes of the same color were taken respectively BCG vaccine and diphtheria vaccine 0.5ml, and two syringes placed in the same cold pack. Inoculation, mistakenly equipped with a syringe of Bacillus Calmette-Guérats, as baibai broken, give the baby upper arm deltoid intramuscular injection of 0.5 ml. The day after finding the wrong kind, immediately find the baby, stay in hospital to see, at the same time level report to the higher authorities. The baby had a cold and fever on August 3, and he improved after taking the drug. After being mistaken, the next morning at 3 am, body temperature 39.1 ℃. The original fever, cough and other symptoms increased, and transient shortness of breath. Deep injection site can reach the diameter of 1cm ~ 2cm nodules. hospital