Corrective action:
Dispatch request was cancelled after the detection.
Preventive action:
For the prevention of similar situations, an extra training related to the selection of the medications was conducted for the employees. In future , all incoming medications will be placed into boxes with vacant spaces in reserve - in order to take the components out without damaging them during selection.
Conclusion:
During the selection of the order #99224 kit №1364908 , a broken tampered seal was detected. On the basis of the investigation’s results, it was determined that the cause of the seal's breakdown was mishandling of the kit which might be due to having the kits being too tightly packed . In accordance with the investigation results , a decision was made to pack less kits per box so that selection of medicines will not lead to further damages. An extra training SOP (FCS/RUS/SOP/027 "Distribution order processing") was assigned.