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Volume 31, Issue 12
A required time frame should not be the driving force behind root cause investigations, says Susan Schniepp, executive vice-president of Post-Approval Pharma and Distinguished Fellow, Regulatory Compliance Associates.
Q. I have just been promoted to be in charge of investigations for my company. Our standard operating procedure (SOP) requires us to complete investigations in 30 days. Depending on the nature of the investigation and to meet the SOP requirement, I have started to close investigations at the 30-day time point even though I think the investigation might not be complete. Sometimes I have had to re-open investigations because the problem recurs, confirming that the investigation was not completed. Do I have a compliance risk if I continue with this practice?
A. The short answer is yes, you have a compliance risk. You probably also have a data integrity issue and a quality culture issue to accompany your compliance risk. There is no time element associated with conducting investigations. Thirty days is an arbitrary number pharmaceutical companies impose on themselves. The US Code of Federal Regulations states “… if errors have occurred, that they have been fully investigated” (1), and “Any unexplained discrepancy … shall be thoroughly investigated, whether or not the batch has already been distributed” (2). Europe’s EudraLex also addresses investigations by stating, “An appropriate level of root cause analysis should be applied during the investigation of deviations …” (3). None of these citations indicate a time for completion of an investigation. What they do imply is that investigations need to be thorough and determine root cause. In some cases, the investigation and root cause can be easily determined in the defined SOP time frame of 30 days. In other cases, the investigation may be more complicated and could exceed the time frame requirement of 30 days. To address this potential discrepancy, your SOP should allow for investigation extensions. The length of the extension request should be made based on the complexity of the investigation.
When an investigation is rushed, the organization leaves itself vulnerable. Suppose, for example, you have a second shift manufacturing operator who continually forgets to sign a step in the batch record for a specific product. This operator is the only one who seems to have this issue. Your initial investigation into the first occurrence of the issue determines a root cause of human error. Because the operator works on the second shift, it is inconvenient to interview him directly, so you rely on the word of his supervisor that this was just a case of human error. You decide to retrain the operator on the proper use of filling out the form and skip the operator interview in order to complete the investigation and perform the retraining in the allotted 30-day time frame.
A few weeks later, the same operator makes the same mistake. You review the previous investigation, arrive at the same conclusion, and perform the retraining of the operator emphasizing the importance of correctly filling out the batch record. This scenario repeats itself 10 times over the course of four months. You finally decide to question the ability of the operator to do the job correctly and bring your concerns to management.
Your boss asks if anyone has interviewed the operator directly to find out why he is having this issue with the batch record. You say no, that you have relied on the opinion of the supervisor. The boss recommends you interview the operator before demoting him.
When you talk to the operator, he informs you that in order to sign the batch record when it needs to be signed, he needs to exit the aseptic core, degown, sign the batch record, and regown, leaving the product unattended during that time. The operator tells you he chose to stay with the product and sign the batch record later but sometimes forgot after the manufacturing run. In this simple exchange with the operator you realize that the root cause of the repeat deviation is not a result of human error but a result of poor process flow.
The question you need to address now is how were other operators handling the situation? By not taking the time to perform the initial investigation thoroughly, you have created a data integrity nightmare because you now need to review all the batch records completed by the other operators to determine if the product is still acceptable.
Admittedly, this is a simplistic example, but it certainly exemplifies the importance of opting to perform a complete and thorough investigation over meeting an artificially imposed time frame. Explaining to an inspector during an audit that you didn’t perform a thorough investigation because you needed to meet an arbitrary time frame is not a position you want your company to be in. You also don’t want to explain why you closed an investigation to meet the time frame and then felt compelled to reopen it after the batch was released because you had concerns about its conclusions.
The other element that needs to be addressed is that of the prevalent culture existing in the organization. It is good to set a time goal for performing investigation, thus ensuring their timely completion. It is not acceptable to have the time frame be the driving force behind the investigation. Management needs to emphasize their commitment to having thorough investigations as opposed to incomplete investigations that meet the self-imposed time frame. It is ideal when an investigation is completed and a true root cause identified in the specified time frame but, if that is not achievable, management needs to be clear that they prefer the identification of the true root cause over the rushed investigation that merely checks the box for completion in a timely manner. Without this management commitment, the premature closing of investigations will likely continue.
Investigations need to focus on determining root cause in a timely manner. The length of time it takes to complete an investigation depends on the complexity of the investigation. The primary driver for avoiding compliance and data integrity risks concerning investigations is arriving at a root cause in a timely manner. This allows you to be confident in presenting your investigations during inspection and avoiding unnecessary scrutiny when the investigation is rushed and a conclusion is reached prematurely.
1. FDA, 21 CFR 211.22(a), Current Good Manufacturing Practice for Finished Pharmaceuticals, Responsibilities of Quality Control Unit, Sept. 29, 1978.
2. FDA, 21 CFR 211.192, Current Good Manufacturing Practice for Finished Pharmaceuticals, Production Record Review, Sept. 29, 1978.
3. European Commission, Eudralex, Volume 4, Good Manufacturing Practice (GMP) guidelines, Chapter 1–Pharmaceutical Quality System (EC, January 2013).
Vol. 31, No. 12
When referring to this article, please cite it as S. Schniepp, "Investigation Timeliness vs. Thoroughness: Finding the Right Balance," BioPharm International 31 (12) 2018.