Warehouse & Logistics Incidents-Wrong material issuance (mix-up in API/excipient/packing material)

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Incident Report No.: IR/WH/2025/050
Incident Raised By: (Name, Sign & Date)
Department: Warehouse / Production
Date of Incident: 29-Aug-2025
Time: 09:40 AM

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


(SECTION I) Description of the Incident:

During dispensing for Batch No. TBL/2025/141, it was observed that Microcrystalline Cellulose (MCC) was issued instead of Lactose Monohydrate. The error was identified during material cross-verification in the dispensing area by Production Executive before addition into the mixer. Wrong material label was detected, and the material was immediately segregated.


(SECTION II) Immediate Action:

  • Issuance and dispensing process was immediately stopped.
  • Wrongly issued container was quarantined and labeled as “Rejected – Wrong Issuance”.
  • Correct material (Lactose Monohydrate) was re-issued from warehouse after QA verification.
  • Incident reported to QA and Warehouse Head for assessment.

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


Preliminary Investigation (Root Cause for Incident):

  • Warehouse operator picked wrong container from adjacent location due to similar packaging of excipients.
  • Secondary verification (by another warehouse staff) was not done before issuance.
  • Material storage racks lacked clear visual differentiation / segregation of similar-looking excipients.

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:

  • Quarantine and reconcile wrongly issued material.
  • Issue correct material as per BMR requirements after QA confirmation.

Preventive Action:

  • Enforce two-level verification system during material issuance (Warehouse + QA).
  • Introduce barcode / ERP scanning system for issuance to avoid manual errors.
  • Rearrange warehouse storage with color coding & segregation of APIs and excipients.
  • Train warehouse staff on importance of correct material issuance and reconciliation.

Responsible Staff: Warehouse Supervisor (Name, Designation)
Target Date for Completion: 15-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:

  • Since error was identified before material was added into the batch, there was no impact on product quality.
  • Incident considered as near-miss with high risk potential.
  • Emphasis on preventive measures and strict adherence to SOP for issuance.

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:
No commercial loss, only time delay of ~1 hour in batch dispensing.
Remarks: Incident Closed.

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

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