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Standard Operating Procedure (SOP) for Handling and Management of Incident / Deviation under the Quality Management System (QMS) in a pharmaceutical plant.
Handling and Control Procedure for Incident / Deviation
1.0 PURPOSE:
- This Standard Operating Procedure (SOP) defines the key elements and requirements for reporting, documenting, evaluating, managing and resolving deviations/incidents from cGxPs approved specifications and/or procedures.
2.0 SCOPE:

- This SOP is applicable for incident/deviation from cGxPs, approved specifications and/or any established procedures including but not limited to-
- Batch Manufacturing Records (BMR),
- Batch Packaging Records (BPR),
- Warehouse and distribution of drug products intended for use in humans, as well as drug substances at the pharmaceutical manufacturing plant.
- Note: 1. Events related to equipment or machine breakdown shall be recorded. Due to breakdown if the product is impacted then deviation shall be raised.
- This procedure is not applicable for out of specification , manufacturing, and analysis of trial batches, method development, and method transfer activities, OOS.
3.0 REFERENCES TAKEN FOR SOP OF INCIDENT / DEVIATION:
- SOP for Handling of Corrective and Preventive Actions
- Change Control Management SOP
- SOP for Q uality Risk Management
4.0 RESPONSIBILITY:
Quality Head/Designee shall be responsible for-
- The oversight and assessment of the deviation/incident.
- Reviewing and approving the deviation/incident.
- Approving requests for extension of timelines for deviation/incident closure.
- Timely resolution of all deviations/incidents.
- Assuring timely implementation of corrective actions and preventive action and ensuring corrective actions and preventive action is effective.
- Reviewing and approving the deviation/incident.
- Classification of the deviation/incident.
- Reviewing requests for extension of timelines for deviation/incident closure.
- Deriving appropriate CAPA and ensure adequate implementation of CAPA.
- The Disposition of impacted products/batches and/or releases other controls, based upon investigation conclusions of the deviations/incidents and associated corrections.
- Taking necessary action to notify customers and Regulatory Agencies about the deviation/incident, wherever applicable.
Manufacturing Head/ Designee shall be responsible for-
- Ensuring all manufacturing deviations are reported to the QA on the day of discovery.
- Ensuring that resources are available to support the deviation/incident and its resolution.
Quality control (QC) head /Designee shall be responsible for-
- Ensuring all deviations/incidents in the laboratory are reported to the QA on the day of discovery.
- Ensuring resources are available to support the deviation/incident and its plan assisting the QA as needed.
5.0 ABBREVIATIONS:
6.0 DEFINITION OF TERMS USED IN SOP FOR INCIDENT / DEVIATION:
Acceptance Criteria:
- The product specifications and acceptance/rejection criteria, such as acceptable quality level and unacceptable quality level, with an associated sampling plan, that are necessary for making a decision to accept or reject a lot or batch (or any other convenient subgroups of manufactured units).
- The criteria, a system or process must attain to satisfy a test or other requirements.
Assessment:
- The act or process, of evaluating (e.g. extent, magnitude, position, impact or compliance level) of a process, system, project, action or activity.
Corrective and Preventive Action:
- A concept with current Good Manufacturing Practice (cGMP) that focuses on the systematic investigation of root causes of unexpected incidences to prevent their recurrence (corrective action) or to prevent their occurrence (preventive action).
- Corrective Action: Action taken to eliminate the causes of an existing non-conformity, defect or other undesirable situation, in order to prevent recurrence.
- Preventative Action: Action taken to eliminate the cause of a potential nonconformity, defect or other undesirable situation, in order to prevent occurrence.
Cross Functional Team :
- Diverse team members (SME) typically comprised of heads from Quality, Manufacturing, Qualified Person, Regulatory, Laboratory or their qualified designees used to review and provide a disposition for the proposed deviation.
cGxP:
- cGxP is a general term that stands for current Good “x” Practice (x = Clinical, Engineering, Laboratory, Manufacturing, Documentation, Pharmaceutical, etc.).
- The titles of these Good “x” Practice guidelines usually begin with “Good” and end in “Practice”. cGxP represents the abbreviations of these titles where “x” a common symbol for a variable, represents the specific descriptor.
- Correction: Immediate action taken to resolve finding/issue.
- Any departure from established standards that has caused or has high probability of causing adverse impact on product safety, quality, identity, potency or purity.
Deviation:
- Any departure (planned or unplanned) from approved procedures or records, including, but not limited to Standard Operating Procedure, Master Production Record, Batch Production Record, Standard Testing Procedure or the failure of a batch or any of its components to meet any of its specifications shall be documented and explained.
- Potential product quality impacting events shall be investigated and the investigation and its conclusions shall be documented.
Elimination:
- Errors Eliminate the possibility of error.
- This can be accomplished by eliminating the task. For example, eliminate mixing errors by purchasing pre-mixed materials.
- Eliminate recording errors by directly linking the measurement device to a printer.
- Event: Any unforeseen happening or unexpected occurrence.
- Incident / Unplanned Deviation– Owner: An individual responsible for initiating the event/incident investigation, determines root cause and implements corrections.
Incident/Unplanned Deviation:
- An unplanned or uncontrolled/unexpected GMP incident or deviation or an event in the form of departure from the designed systems or procedures at any stage of material receipt, manufacturing, packaging, testing, holding and storage of drug substance and it is Intermediate/Components due to system failure or equipment breakdown or human interventions and observed at a later time during execution, audit, etc.
- Initiator – Incident/Unplanned Deviation: An individual who initiates an event/incident record.
- Initiator – Temporary Change / Planned Deviation: Functional Supervisor or higher level person who initiates a Temporary Change or a Planned Deviation record.
- Investigation: A documented logical and/or scientific review of data related to all quality events that leads to the identification of the root cause and corrective and preventive action.
- Nonconforming Material: Material that does not meet specified acceptance criteria.
- Operating Group: Responsible Person(s) who execute Temporary Change/Planned Deviation along with other department member/team member.
Risk Assessment:
- A systematic process of organizing information to support a risk decision to be made within a risk management process.
- It consists of the identification of hazards and the analysis and evaluation of risks associated with exposure to those hazards.
- The underlying (fundamental) reason for a detected quality issue/failure (non-conformity, defect or other undesirable situation), which, if eliminated or corrected, will prevent recurrence of the problem for the same reason.
- Subject Matter Expert: An individual, who is educated, trained and/or highly experienced in a particular field or subject
- Task: Any activity identified as a part of executing a ‘Temporary Change’ or ‘Planned Deviation’. Tasks can be of two types, i.e., pre-requi (to be completed before execution of the temporary change or planned deviation) and non-pre-requi (can be completed concurrently with execution of the temporary change or planned deviation).
Temporary Change/ Planned Deviation:
- A temporary or interim need to deviate from a current approved requirement or to supplement, clarify or correct existing approved requirements. The term “temporary change/ planned deviation” is frequently used to describe a decision to carry out a process in a different way from which it is established in a SOP, Method or Manufacturing Batch Record.
- (e.g. a reprocess) due to an unforeseen event. Temporary change or Planned deviation need to be fully documented and justified. Usually, these are associated with onetime events or ‘Temporary Changes’ and the change control system must be used for permanent changes
7.0 PROCEDURE FOR HANDLING OF INCIDENT / DEVIATION:
Incident/ Unplanned Deviation:
- Any person (Initiator) can identify incident/unplanned deviation and shall initiate an incident/unplanned deviation record.
- It shall be reported to supervisor immediately and documented in the system on the day of discovery, but not later than end of next working day; a unique identification number shall be assigned to the record.
- Quality Assurance shall be informed within one (1) working day of discovery of the incident.
- QA shall assign the unique identification number for deviation as given below:
- It shall be in the format of “PB/ADV/YY/NNN”.
- BS : Location Code (PB stand for Pharma Beginners)
- A : U or P (Where U is stand for unplanned/Incident and P is stand for planned.)
- YY : Year of event Last 2 digit of year (20 for 2020 and so on.)
- NNN : Serial number of deviation.
- Every year, 3 digit serial numbers shall start from 001 and shall run continuously irrespective of the change in department code.
- e.g. First unplanned deviation of 2020 shall be PB/UDV/20/001, second planned deviation of 2020 shall be PB/PDV/20/002.
- QA shall make necessary entry in deviation log as per Annexure 2.
- QA shall issue the deviation form to initiator trough the document request form.
The Initiator shall provide the following information, but not limited to, as applicable:
- Name of the department(s) involved
- Name of block to which event/incident belongs / area
- Event/incident category and sub-category
- Description of the event observed, other related comments
- Results file/document shall be attached (if any)
- Product details- include other potentially impacted batch/batches event/incident
- Product stage, equipment involved (name and ID)
- Procedures/documents involved (SOPs, process documentation or product/material specifications)
- Document affected electronic systems impacted (computer information Technology, hardware or software)
- Document related product/material test results
- Supplier(s) – identify material vendor(s) involved with the event event/incident batches under test, which are not yet released, shall be put on “Hold” status along with other batches identified for restriction.
- After initiating an incident/unplanned deviation, the initiator may cancel the record, if required.
- The cancellation shall be supported by valid justification / rationale and submitted to QA prior to closure of the deviation record.
- The Initiator shall describe details such as affected product, system, process and other relevant technical information while describing the incident/unplanned deviation.
- Speculation shall be avoided; any deductions or assumptions made shall be identified as such. Relevant questions to be considered include, but are not limited to, the following:
What is the potential impact of the incident/unplanned. deviation upon the safety, identity, strength, purity and quality of the finished product?
- In technical terms what is the incident/unplanned deviation about?
- When it was first observed?
- When and where did it occur?
- What is the extent or scope, including a description of all lot(s) and product(s) potentially impacted?
- When was the source of the incident/unplanned deviation last seen functioning properly (as expected)
- Who made the observation (include job title of individual)?
- A rationale for inclusion or exclusion of lots shall be documented in the report.
- All known events, such as the following, shall be documented in the report:
- Compliance with registration
- Incident/unplanned deviation from process validation
- Impact on product safety or efficacy