Quality & GMP Incidents-Packaging Error (wrong label / misprinted batch number / missing leaflet)

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Incident Report No.: IR/PKG/2025/048
Incident Raised By: (Name, Sign & Date)
Department: Packaging
Date of Incident: 29-Aug-2025
Time: 04:30 PM

Category: ☑ Quality Impacting Incidents ☐ Quality Non-Impacting Incidents


(SECTION I) Description of the Incident:

During the secondary packaging of Batch No. TBL/2025/122, it was observed that carton labels contained incorrect batch number (TBL/2025/212 instead of TBL/2025/122). Additionally, in one case, cartons were found without product leaflet (Patient Information Leaflet). The error was identified by QA during in-process packaging inspection.


(SECTION II) Immediate Action:

  • Packaging activity was immediately stopped.
  • All packed cartons were quarantined and labeled as “On Hold – Pending QA Decision”.
  • Suspect labels and cartons were segregated for reconciliation.
  • Packaging line was cleared and documented.

Action Taken By: Packaging Officer (Name, Sign & Date)
Action Checked By: Packaging Head (Name, Sign & Date)


Preliminary Investigation (Root Cause for Incident):

  • Wrong label: Misplacement of label rolls during line setup, not cross-verified.
  • Missing leaflet: Operator oversight during manual leaflet loading in cartonator machine.
  • Inadequate line clearance before batch start.

Department Head: (Sign, Date & Name)


(SECTION III) Classification of Errors / Events responsible for Incident:

☐ Breakdown of an Equipment / Instrument / Utility Machine
☐ Malfunctioning of an Equipment / Instrument / Utility Machine
☐ Power Failure
☐ Documentation Error
☑ Human Error
☐ Others


(SECTION IV) Suggested Corrective Action & Preventive Action To Be Taken:

Corrective Action:

  • Stop packaging and perform 100% check of packed cartons for correct batch number and leaflet presence.
  • Destroy incorrect labels as per SOP for reconciliation.

Preventive Action:

  • Introduce dual verification (by Packaging + QA) for label roll and leaflet before line startup.
  • Train packaging staff on importance of line clearance and reconciliation.
  • Implement barcode scanning system for label verification.
  • Automate leaflet insertion with sensor-based detection to prevent missing leaflets.

Responsible Staff: Packaging Supervisor (Name, Designation)
Target Date for Completion: 12-Sep-2025

Suggested By: Department Head (Sign, Date & Name)
Reviewed By: Plant Head (Sign, Date & Name)


(SECTION V) Evaluation and Recommendation by QA / VP Technical:

  • Perform 100% physical check of all cartons from this batch.
  • If discrepancies are corrected and results comply, batch may be released.
  • QA to verify destruction records of incorrect labels.

Q.A. Head / VP Technical: (Sign, Date & Name)


(SECTION VI) Compliance of the Recommendations and Closure:

Verification Done By:

  • Department Head (Sign, Date & Name)
  • QA Head / VP Technical (Sign, Date & Name)

Final Conclusion with Estimated Commercial Loss:
Estimated loss of ~500 misprinted cartons & labels; batch release delayed by ~1 day.
Remarks: Incident Closed.

Head of Quality Assurance Department / VP Technical: (Sign, Date & Name)

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