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Deviations Permissibility & Handling in GMP
(Tutorial-4)
Roohi B. Obaid
19 May 2018 at Karachi
[143 slides]
Knowledge Sharing Exercise
To Learn through Debate, Discussion &
Experience of others
This presentation discusses Regulatory Science,
nothing more & nothing less
Reference: US-FDA Documents / Scientific Articles/
Real time hands on experience of Compliance & Enforcement
Personal point of view & nothing to disclose
Disclaimer
Deviation
Deviation
Divergence
Disobedience
Change
D
D
C
Deviation
Departure from an
approved instruction
or established
standards
Handling of Deviations
Absolute Fact
The drug which is tested is not used & the drug
which is used is not tested
Absolute Fact
Certainty
Probability
Control on Manufacturing Process
Q
Absolute Fact
Product quality depends on each step in
manufacturing process must be controlled to
maximize the probability and enhance certainty
that the FPP will meet its quality, design
specifications, perform well & uphold promise
Quality System
OOS Deviations
Recall & Returns Complaints
Risk Management
Change Management
Deviation
GMP
Mistakes
or Error
Reprocessing or Rework
Unapproved changes
Performing an activity without proper training
Outside of operating parameter or in-process control limit
Failure to follow SOP or approved batch record instructions
Departure from an
approved instruction
or established
standard
Departure from an
approved instruction
or established
standard
e.g. Soaking
Departure from an
approved instruction
or established
standard
Departure from
approved procedure
or established
specifications
e.g. Soaking
Departure from an
approved instruction
or established
standard
Departure from
approved procedure
or established
specifications
e.g. Soaking
e.g. Water bath
Obligation
ANY deviation from established procedure should be documented
and explained. Critical deviations should be investigated, and the
investigation and its conclusion should be documented
[ICH]
Obligation
Document
Explain
Investigate
Document
Obligation
Written procedure should be established & followed for
investigating critical deviations or the failure of a batch … the
investigation should extend to other batches that may have been
associated with the specific failure or deviation
[ICH]
Obligation
Failure
Deviation
Written
SOP
Investigation
Obligation
Deviation in yield associated with critical
process should be investigated to determine
their impact or potential impact on the resulting
quality of affected batches
Obligation
Any deviation should be evaluated to ensure that there
is no detrimental effect upon the fitness for the purpose
of material (intermediate, API, etc.)
Obligation
Deviation from approved standard of calibration on critical
instrument should be investigated to determine if these could have
had an impact on quality of …. Manufactured using this
equipment since last successful calibration
Obligation
Obligation
All deviation, investigation and OOS reports should be reviewed
as part of the batch record review before the batch is released
Obligation
Evaluation report that cross refers the validation protocol should
be prepared, summarizing the results obtained,
commenting on any deviation observed
& drawing the appropriate conclusion, including recommending
changes to correct deficiencies
Types ?
Activity performed
differently and or
modified than that
specified in an
approved document
Types ?
Activity performed
differently and or
modified than that
specified in an
approved document
Planned
Un-planned
Planned Deviation
Planned Deviation Pre-described, Pre-approved for specified
period for specific number of batches
Planned Deviation
Pre-described, Pre-approved for specified
period for specific number of batches
Feb 2016
Annual Maintenance
60 Batches .. One batch
per day
Jan 2016
Mfg ..
Schedule 5 to 10 Feb
Planned Deviation
Pre-described, Pre-approved for specified
period for specific number of batches
Approved well before execution
Handled through approved change control procedure
Changes should be evaluated for product impact significance
Planned Deviation
Unintentional
Pre-described, Pre-approved for specified
period for specific number of batches
Un-planned
Unexpected
Un-Planned Deviation
Uncontrolled event in
the form of non-
compliance at any stage
of manufacturing etc.
Incident
Quality
impacting
(purity, strength,
release, delivery etc.)
Non-quality
impacting
Sec. packaging, out of
trend, yield etc.)
Major
Critical Minor
Quality
impacting
(purity, strength,
release, delivery etc.)
Non-quality
impacting
Sec. packaging, out of
trend, yield etc.)
Typical examples Temperature,
humidity, air
pressure
Breakdown of
process
equipment
Equipment out
of calibration
Typical examples Alternative
equipment
used
Process done
but not
documented
In-process
control limit
went out
Take Home Message
Your corrective
action must not be
Biased
&
must Match with
potential root cause
Take Home Message
The purpose of
conducting
investigation
must not be to
release the batch
Take Home Message
…
It is to determine the
root cause for the
deviation
Take Home Message
…
It is to implement
appropriate &
meaningful CA
Take Home Message
…
It is to evaluate the
implicated system
Investigating
Steps
Investigating
Steps
Discovery of
deviation
Documentation
of events
Immediate
corrective
action
Investigation of
root cause
Casual analysis
Corrective
action
Preventive
action
Effectiveness
evaluation
Review &
reshape the
policy
Investigation
Investigation
What was
discovered
Who was
involved
When did the
event occur
Where did the
deviation occur
How was the
deviation
discovered
How frequently
does the
process occur
Investigation
Remember, there is a big difference b/w
What happened & Why happened -OR- What happened & How happened
What was
discovered
Who was
involved
When did the
event occur
Where did the
deviation occur
How was the
deviation
discovered
How frequently
does the
process occur
Investigation
Fundamental questions
What Happened
Why How
Why
eg.
Dissolution failure
Remember
Deviation is a
beauty
It evolves
knowledge and
science, but …
Remember
Deviation is a
beauty
It evolves
knowledge and
science, but …
Don’t let it affect your product
quality, performance & promise
Obligations & Emerging Expectations
Significant
deviations are fully
investigated
Every deviation is
fully recorded
Assessment of
deviations from
specified procedures
Incorporate risk
assessment
Focus deviations on
Periodical Quality
Reviews
Authorization for
deviations from
manufacturing
formula, process,
packaging & testing
instructions
Policies, procedures,
records of actions
that took part in
construction of
decision for
deviation
Policies, procedures,
records of actions
that took part in
construction of
decision for
deviation
DOCUMENT
What have been
done to avoid it?
Why it was
unavoidable
What have been
done to avoid it?
Why it was
unavoidable
REASON?
Any signal deviating
from trend will be
investigated
Deviations in
stability programs,
no matter it is
authorized
Quality System staff are
effectively integrated into
manufacturing & involved in
non-conformance
investigation
Investigation,
conclusion & follow up
must be documented
Justify deviations
from the written
procedures
Don’t leave any failure
uninvestigated, no
matter, batch is
destroyed or already
been consumed
Investigation will
always be extended
to other batches &
reason of limit will
justify
Let’s Recap through discussion
Deviations
Deviations
1
2
3
4
Deviations
1
2
3
4
Use of Tray Dryer instead of FBD
Deviations
1
2
3
4
Exceeded the time specified for
boiling a liquid e.g. > 10 min
Deviations
1
2
3
4
Used the wrong sieve no. for sieving
Deviations
1
2
3
4 Changed the mixing order of
ingredients during batch processing
Non-
Conformance
1
2
3
4
Non-
Conformance
1
2
3
4
Work done but not recorded
Non-
Conformance
1
2
3
4
Line clearance not done,
another batch started
Non-
Conformance
1
2
3
4
Change in size of packaging
by supplier
Non-
Conformance
1
2
3
4 Testing by a person who is not
qualified for the purpose
Non-
Conformance
Incident
1
2
3
4
Incident
1
2
3
4
Sieve break during operation
Incident
1
2
3
4
Material dropped on the floor while
shifting to hopper
Incident
1
2
3
4
Mix up of 40 mg & 240 mg label
Incident
1
2
3
4 Blister machine suddenly
malfunctioned
Incident
Discrepancy
1
2
3
4
Discrepancy
1
2
3
4
Yield / Inventory
Discrepancy
1
2
3
4
Temperature / Humidity
Discrepancy
1
2
3
4
Monitoring devices
Discrepancy
1
2
3
4 Measuring equipment
Discrepancy
… A multiple injection manufacturing facility
Injection X 500 mg / 10 ml always found with yield 103 to 104%
Assay trend moves in between 101 to 103%
Process loss of 3 to 6% for other injection products
Lets think what is going on …
?
System ProcessKey
steps
System
Tools: Policy, SOP, Forms, Register, Process Flow
Incorporate risk assessment into process
Train staff in whole process including risk ..
System
Ensure procedure is understood & followed
Track progress of each deviation
Ensure timely closure
System
Periodical review of deviations
Trend & pattern of repeat events
Strategy to move forward
Process
Process
Raise ASAP
Complete
initial detail
Assess
criticality
Corrections
Investigation Assess risk Corrections Conclusion
Corrective
action
Preventive
action
Close Reviews
Closing Deviations
8
1 Write up the investigation in detail
2 Explain what happened & why
3 Identify & document root cause(s)
4 Detail corrections & corrective actions
5 Ensure CAPA are raised
6 Reviewed by Quality Assurance
7 Final closure by Quality Assurance
8 Record closure & maintain register
Take Home Message
Make sure that policy,
procedures, forms, process
flow are well understood &
aligned to walk and talk
together
Take Home Message
Appropriate training &
trained staff for investigations
is inevitable to reach logical
decisions that satisfy
regulatory expectations
Take Home Message
Be simple
Don’t make the process
unreasonably complicated or
over complicated
Take Home Message
Don’t expect that everyone
can be a good investigator
Common Problems
1 Poor investigation
2 Not addressing facts/ignoring evidence
3 Only considering one root cause
4 Poor scientific basis
5 Making & stucking on assumptions
6 Not raising CAPA
7 Repeat deviations
8 Leave assessment of impact on other batches
… Tablet 400 mg instead of 200 mg
Same product of two different strengths … Proportionality in
granulation was same … Batch was compressed for 400 mg tablet
Packaging jar was labeled for 200 mg … All documents were
prepared for 200 mg except compression …
Lets think what can be done …
?
… Evaluation of supplier competence
Glass bottles
We have to monitor and review the performance as per QMS
Lets think what can be done …
?
Remember
Deviation is not allowed if not justified in
Quality System
Document to ensure that history of the product can be traced back with regard to
concerning personnel, equipment, materials, process etc.
Remember
Handling of non-conformance or deviations
are key component of Quality System
Document investigation, conclusion and follow up to ensure that product confirms
to the required expectations. It is inevitable to measure
process & product attributes
Remember
Investigation of discrepancy is critical esp.
when affect product quality
It may be detected at any stage of manufacturing & testing process, it should be
handled appropriately, sometime it may not have an impact on product
Remember
Responsive deviation & investigation system
is a front burner attribute of Quality System
Implementation of Quality System facilitates compliance
and assures consistent production for safe, effective product under a sustainable
and productive environment
Remember
Deviation may be acceptable if
Does not compromise the quality of drug product, it is justified, documented &
comes under microscope for review on regular basis
Remember
Sufficient rigorous scientific evidence &
statistical measures
Remember
Sufficient Rigorous Scientific Evidence &
Statistical Measures
Product and process deviation can be explained scientifically with identifiable root
cause to keep aligned goal of process validation
A closer look at
inspection (MHRA)
Deviations were not
fully recorded and
investigated
A closer look at
inspection (MHRA)
Deviation
investigations did not
include an appropriate
level of investigations
and did not capture all
relevant information
A closer look at
inspection (MHRA)
Quality impact of
deviations and CAPAs
implemented were not
appropriately assessed
A B
Approved for particular
purpose
NOT Approved for
particular purpose
A B
Weighed on B,
but not recorded
Approved for particular
purpose
NOT Approved for
particular purpose
A B
Approved for particular
purpose
NOT Approved for
particular purpose
Weighed on B,
but not recorded
Impact?
Escape from
investigation Trapped in
investigation
Unreasonable
If B goes out of calibration
& investigated for all the
weighing done on it, the
particular batch will escape
from investigation due to
non-recording
If A goes out of calibration
& investigated for all the
weighing done on it, the
particular batch will be
added for no reason in the
investigation
A
• XXX
B
• YYY
C
• ZZZ
A
• XXX
B
• YYY
C
• ZZZ
A
• XXX
C
• ZZZ
B
• YYY
Lets imagine a product/ process/ procedure and think of an instance where
a minimum deviation can greatly impact the product quality
Processing
Parameter
Equipment
Testing
Procedure
Paracetamol suspension
Millions of bottles rejected
PHC Program
Xanthan gum
Process time
Paracetamol tablet
Millions of packs recalled
Product discontinuation for > year
RB
Gelatin
Source
Mixer?
Soft gelatin Formulation
Millions of capsules recalled
Manufacturing site closed for > year
MK
Gelatin
Source
Stability
study?
XXX HC Cream
Product discontinued
RB toll mfg GZ
Testing
method
Interpretation
w/o scientific
support
Paracetamol suspension
Millions of bottles rejected
PHC Program
Particle size
change
Stability
study?
Benzyl Benzoate Lotion
Millions of bottles rejected
??????
Order of
mixing?
Processing
temperature?
PVP Solution
Thousands of bottles rejected
??????
Cap change?
Potency loss?
Salbutamol SR/ Cetrizine tablet
Stop manufacturing
??????
Release w/o
dissolution?
Critical
deviation?
2X mg X mg
1/2X
mg
Thank You

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