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1. Faculdade de Medicina da Universidade Federal de Uberlândia, Uberlândia, MG, Brazil. 2. Curso de Enfermagem da Universidade Federal de Uberlândia, Uberlândia, MG, Brazil., 3. Escola Técnica de Enfermagem da Universidade Federal de Uberlândia, Uberlândia, MG, Brazil. Address to: Dr. Sérgio de Andrade Nishioka. Faculdade de Medicina/UFU. Av. Pará 1720, 38400-902 Uberlândia, MG, Brazil. e-mail: snishioka@umuarama.ufu.br. Recebido para publicação em 17/9/2002. Dr. Rabello and colleagues2 recently reported their investigation of 14 patients who were unintentionally given a dose of yellow fever vaccine (YFV) that was 25fold as high as that recommended. Their findings are very important to reassure health professionals who may come across a similar situation. This incident from Contagem is the only one that we have seen reported in the literature. We would like to report a similar case, concentrating our discussion on the identification of the causes for error and on suggesting preventive measures.

Overdose of yellow fever vaccine: a preventable error?