Enhancing Pharmaceutical Product Quality With a Comprehensive Corrective and Preventive Actions (CAPA) Framework: From Reactive to Proactive.

Corrective and preventive actions (CAPA) are crucial components of quality assurance (QA) within the pharmaceutical industry, essential for maintaining product quality, safety, and regulatory compliance. The review explores the multifaceted role of CAPA in pharmaceutical manufacturing, emphasizing its structured approach to detecting, addressing, and preventing quality issues. CAPA systems are integral to the broader quality management system (QMS), functioning as a dual-loop mechanism that is reactive and proactive approach aligned with continuous improvement principles outlined by the International Organization for Standardization (ISO) 9001:2000. It details the three distinct phases of CAPA: correction or remedial action, corrective action (CA), and preventive action (PA). It highlights the importance of root cause analysis and the necessity for immediate corrections and long-term preventive measures to avoid recurring issues. Regulatory expectations, such as those from the Food and Drug Administration (FDA) under the Code of Federal Regulations (CFR) title 21 part 820 and the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) Q10, are discussed, underscoring the need for a comprehensive CAPA plan that integrates data analysis and ongoing process enhancements. Additionally, the paper introduces the 8D methodology as a structured problem-solving approach to complement CAPA efforts. By providing an in-depth examination of CAPA procedures and their implementation, this article aims to contribute to the understanding and effectiveness of quality systems in pharmaceutical manufacturing.

Efficacy of Peracetic Acid and Chlorine on the Reduction of Shiga Toxin-producing Escherichia coli and a Nonpathogenic E. coli Strain in Preharvest Agricultural Water.

Produce-borne outbreaks of Shiga toxin-producing Escherichia coli (STEC) linked to preharvest water emphasize the need for efficacious water treatment options. This study quantified reductions of STEC and generic E. coli in preharvest agricultural water using commercially available sanitizers. Water was collected from two sources in Virginia (pond, river) and inoculated with either a seven-strain STEC panel or environmental generic E. coli strain TVS 353 (∼9 log10 CFU/100 mL). Triplicate inoculated water samples were equilibrated to 12 or 32°C and treated with peracetic acid (PAA) or chlorine (Cl) [low (PAA:6ppm, Cl:2-4 ppm) or high (PAA:10 ppm, Cl:10-12 ppm) residual concentrations] for an allotted contact time (1, 5, or 10 min). Strains were enumerated, and a log-linear model was used to characterize how treatment combinations influenced reductions. All Cl treatment combinations achieved a ≥3 log10 CFU/100 mL reduction, regardless of strain (3.43 ± 0.25 to 7.05 ± 0.00 log10 CFU/100 mL). Approximately 80% (19/24) and 67% (16/24) of PAA treatment combinations achieved a ≥3 log10 CFU/100 mL for STEC and E. coli TVS 353, respectively. The log-linear model showed contact time (10 > 5 > 1 min) and sanitizer type (Cl > PAA) had the greatest impact on STEC and E. coli TVS 353 reductions (p < 0.001). E. coli TVS 353 in water samples was more resistant to sanitizer treatment (p < 0.001) indicating applicability as a good surrogate. Results demonstrated Cl and PAA can be effective agricultural water treatment strategies when sanitizer chemistry is managed. These data will assist with the development of in-field validation studies and may identify suitable candidates for the registration of antimicrobial pesticide products for use against foodborne pathogens in preharvest agricultural water treatment.

Sanitizer Type and Contact Time Influence Salmonella Reductions in Preharvest Agricultural Water Used on Virginia Farms.

No Environmental Protection Agency (EPA) chemical treatments for preharvest agricultural water are currently labeled to reduce human health pathogens. The goal of this study was to examine the efficacy of peracetic acid- (PAA) and chlorine (Cl)-based sanitizers against Salmonella in Virginia irrigation water. Water samples (100 mL) were collected at three time points during the growing season (May, July, September) and inoculated with either the 7-strain EPA/FDA-prescribed cocktail or a 5-strain Salmonella produce-borne outbreak cocktail. Experiments were conducted in triplicate for 288 unique combinations of time point, residual sanitizer concentration (low: PAA, 6 ppm; Cl, 2-4 ppm or high: PAA, 10 ppm; Cl, 10-12 ppm), water type (pond, river), water temperature (12°C, 32°C), and contact time (1, 5, 10 min). Salmonella were enumerated after each treatment combination and reductions were calculated. A log-linear model was used to characterize how treatment combinations influenced Salmonella reductions. Salmonella reductions by PAA and Cl ranged from 0.0 ± 0.1 to 5.6 ± 1.3 log10 CFU/100 mL and 2.1 ± 0.2 to 7.1 ± 0.2 log10 CFU/100 mL, respectively. Physicochemical parameters significantly varied by untreated water type; however, Salmonella reductions did not (p = 0.14), likely due to adjusting the sanitizer amounts needed to achieve the target residual concentrations regardless of source water quality. Significant differences (p < 0.05) in Salmonella reductions were observed for treatment combinations, with sanitizer (Cl > PAA) and contact time (10 > 5 > 1 min) having the greatest effects. The log-linear model also revealed that outbreak strains were more treatment-resistant. Results demonstrate that certain treatment combinations with PAA- and Cl-based sanitizers were effective at reducing Salmonella populations in preharvest agricultural water. Awareness and monitoring of water quality parameters are essential for ensuring adequate dosing for the effective treatment of preharvest agricultural water.

Managing a PCR Contamination Event in a Molecular Pathology Laboratory.

Contamination in a molecular laboratory may lead to erroneous results with potential to cause patient harm if not promptly identified and corrected. A general overview of the practices used in molecular laboratories to identify and address contamination once an event has occurred is discussed. The process used to assess the risk associated with the identified contamination event, determine the appropriate course of immediate action, perform a root cause analysis to determine the source of contamination, and assess and document the results of the decontamination process will be reviewed. Finally, the chapter will discuss a return to normal with consideration of appropriate corrective actions to mitigate future contamination events.

Addressing serious and continuing research noncompliance and integrity violations through action plans: Interviews with institutional officials.

Serious and continuing research noncompliance and integrity violations undermine the quality of research and trust in science. When researchers engage in these behaviors, institutional officials (IOs) often develop corrective action plans. Ideally, such plans address the root causes so noncompliance or research integrity violations discontinue. The aim of this study was to identify what IOs perceive as causes and action plan activities typically prescribed. We conducted semi-structured in-depth interviews with 47 IOs at research institutions across the U.S. including: institutional review board and institutional animal care and use committee chairs and directors, chief research officers, research compliance and integrity officers, and institutional conflicts of interest chairs and directors. The most common root causes identified were: 1) lack of knowledge or training, 2) failure to provide research team supervision, and 3) researcher attitudes toward compliance. The most common action plan activities include: 1) retraining in compliance or research integrity, 2) follow-up and hands-on involvement with the researcher, and 3) mandated oversight or mentoring. Because the most commonly identified action plan activities fail to adequately address the majority of root causes, our findings suggest a need for IOs to rethink existing approaches to action plan development to more effectively target root causes.

Content Analysis of US FDA Warning Letters Issued to Compounding Pharmacies Regarding Violations of Current Good Manufacturing Practices Between 2017 and 2022.

Purpose: Assessment of the US FDA-issued WLs content is an educational tool that can be used in the continuous training program of community pharmacists in compounding pharmacies. The study was designed to critically assess FDA warning letters (WLs) issued to compounding pharmacies in 2017-2022 for violations of Current Good Manufacturing Practices (cGMP). Methods: Content analysis was used to evaluate WLs issued concerning (1) type of violations; (2) frequency of violations mentioned in the WLs; (3) specific evaluations of the deviations related to compounded sterile products, and (4) evaluation of corrective measures requested by the US FDA. Results: A total of 141 WLs were evaluated. The main observed violations in the analyzed WLs were adulterated drug products (130), misbranded drugs (103), unapproved new drug products (42), failure to report adverse events (22), and failure to report drugs (11). Other violations were evaluated related to sterile product compounding with emphasis on personnel qualifications, quality control procedures, equipment, etc. Conclusion: The continuous issuance of WLs by the FDA indicates the need for compounding pharmacies become more vigilant to reduce the recurrence of the addressed violations through establishing adequate training/retraining programs. The analysis of issued WLs can serve as a learning tool to help improve compounding procedures, reduce the recurrence of these violations, and enhance patient safeguards. Supplementary Information: The online version contains supplementary material available at 10.1007/s12247-022-09692-4.

Zeroing in on the root cause of the clots in a blood bag: Reinforcing improvement in blood collection practices.

Blood clots in the packed red blood cell [PRBC] unit can sometimes go unrecognized and could eventually give rise to flow problems while administering the same. We herein report our observation of a moderately elongated threadlike clot in a PRBC unit prepared from a whole blood donated by a young Indian male donor. The PRBC unit was returned to us from the ward by the nursing staff citing "flow issues". In fact, this warranted the initiation of root-cause analysis of the entire event led by two faculty members, one post-graduate student and the technical supervisor at our blood centre.

Evaluation of the analytical performance of endocrine analytes using sigma metrics.

BACKGROUND: (a) To evaluate the clinical performance of endocrine analytes using the sigma metrics (σ) model. (b) To redesign quality control strategies for performance improvement. METHODS: The sigma values of the analytes were initially evaluated based on the allowable total error (TEa), bias, and coefficient of variation (CV) at QC materials level 1 and 2 in March 2018. And then, the normalized QC performance decision charts, personalized QC rules, quality goal index (QGI) analysis, and root causes analysis (RCA) were performed based on the sigma values of the analytes. Finally, the sigma values were re-evaluated in September 2018 after a series of targeted corrective actions. RESULTS: Based on the initial sigma values, two analytes (FT3 and TSH) with σ > 6, only needed one QC rule (13S ) with N2 and R500 for QC management. On the other hand, seven analytes (FT4, TT4, CROT, E2, PRL, TESTO, and INS) with σ < 4 at one QC material level or both needed multiple rules (13S /22S /R4S /41S /10X ) with N6 and R10-500 depending on different sigma values for QC management. Subsequently, detailed and comprehensive RCA and timely corrective actions were performed on all the analytes base on the QGI analysis. Compared with the initial sigma values, the re-evaluated sigma metrics of all the analytes increased significantly. CONCLUSIONS: It was demonstrated that the combination of sigma metrics, QGI analysis, and RCA provided a useful evaluation system for the analytical performance of endocrine analytes.

The research misconduct post hoc inquiry as a measure of institutional integrity (DR).

The terms, institutional and scientific, integrity appeared in the literature 986 times from 2005 to 2015. How has the term integrity, with its dual definition, a) The accuracy, completeness and consistency of data and b) the adherence to a code of moral values, been applied to an institution? The authors suggest that a post hoc inquiry be instituted following the finding of an individual act of research misconduct to determine if the sponsoring institution, actively or passively, played a contributory role and if corrective action was taken. This would serve as one measure of institutional integrity.

Listeria monocytogenes environmental sampling program in ready-to-eat processing facilities: A practical approach.

Listeria monocytogenes is a foodborne pathogen that is frequently found in the environment. It can easily enter food processing environments and contaminate food, potentially causing public health issues. Food business operators (FBOs) are responsible for the control of L. monocytogenes in the food processing environment, particularly in facilities producing ready-to-eat food. The design and implementation of an effective environmental monitoring program (EMP) for L. monocytogenes is an integral part of controlling L. monocytogenes. An effective EMP, including all aspects from sampling, to analysis, to data interpretation, to implementation of corrective actions (including food disposition), is a tool that will help with identification and control of L. monocytogenes contamination. It should be used in conjunction with end product testing, not as a replacement for it. An EMP should be specifically designed for a particular facility on a case-by-case risk-based approach, by a food safety team within the facility. It should be reviewed regularly (at least every 6 months) and verified for its effectiveness. The control of L. monocytogenes in the food industry involves the full commitment of management and of all personnel involved with the safety of foods placed on the market, thus reducing the risk of listeriosis to consumers. Several regulatory and guidance documents provide recommendations for designing aspects of an effective L. monocytogenes EMP. However, a comprehensive review of the key components of an EMP in a single document is lacking. The objective of the present review is to provide FBOs with a practical guide to design, implementation, and verification of an EMP tailored by the food safety team for each food business.

Managing Deviating EQA Results: A Survey to Assess the Corrective and Preventive Actions of Medical Laboratories Testing for Oncological Biomarkers.

Laboratories testing predictive biomarkers in lung and colorectal cancer are advised to participate in external quality assessment (EQA) schemes. This study aimed to investigate which corrective actions were taken by laboratories if predetermined performance criteria were not met, to ultimately improve current test practices. EQA participants from the European Society of Pathology between 2014 and 2018 for lung and colorectal cancer were contacted, if they had at least one analysis error or test failure in the provided cases, to complete a survey. For 72.4% of 514 deviating EQA results, an appropriate action was performed, most often including staff training (15.2%) and protocol revisions (14.6%). Main assigned persons were the molecular biologist (40.0%) and pathologist (46.5%). A change in test method or the use of complex techniques, such as next-generation sequencing, required more training and the involvement of dedicated personnel to reduce future test failures. The majority of participants adhered to ISO 15189 and implemented suitable actions by designated staff, not limited to accredited laboratories. However, for 27.6% of cases (by 20 laboratories) no corrective action was taken, especially for pre-analytic problems and complex techniques. The surveys were feasible to request information on results follow-up and further recommendations were provided.

Risk assessment of the total testing process based on quality indicators with the Sigma metrics.

Background Evidence-based evaluation of laboratory performances including pre-analytical, analytical and post-analytical stages of the total testing process (TTP) is crucial to ensure patients receiving safe, efficient and effective care. To conduct risk assessment, quality management tools such as Failure Mode and Effect Analysis (FMEA) and the Failure Reporting and Corrective Action System (FRACAS) were constantly used for proactive or reactive analysis, respectively. However, FMEA and FRACAS faced big challenges in determining the scoring scales and failure prioritization in the assessment of real-world cases. Here, we developed a novel strategy, by incorporating Sigma metrics into risk assessment based on quality indicators (QIs) data, to provide a more objective assessment of risks in TTP. Methods QI data was collected for 1 year and FRACAS was applied to produce the risk rating based on three variables: (1) Sigma metrics for the frequency of defects; (2) possible consequence; (3) detection method. The risk priority number (RPN) of each QI was calculated by a 5-point scale score, where a value of RPN > 50 was rated as high-risk. Results The RPNs of two QIs in post-analytical phase (TAT of Stat biochemistry analyte and Timely critical values notification) were above 50 which required rigorous monitoring and corrective actions to eliminate the high risks. Nine QIs (RPNs between 25 and 50) required further investigation and monitoring. After 3 months of corrective action the two identified high-risk processes were successfully reduced. Conclusions The strategy can be implemented to reduce identified risk and assuring patient safety.

Protective efficacy using Cape- golden berry against pre-carcinogenic aflatoxins induced in rats.

Aflatoxins are harmful compounds that induced carcinogenic impacts on tissues. It could generate oxidative stress causing cells damage. Bioactive substances from natural plants could avoid mycotoxins' bad impacts. Cape-goldenberry (CGB), a source of active substances, was vacuum-dried at 30 °C then milled. Fresh and dried CGB-powder properties were estimated. Animal experiment was designed using six rat-groups to evaluate CBG effect to reduce harmful effect of aflatoxins. Rats treated groups were orally administrated by aflatoxins (AFs) with or without CGB in diets. Blood parameters, liver and kidney functions, serum lipids, and liver histological changes were estimated. The CGB powder showed several time doubles of phenolics, flavonoids, and antioxidants than fresh fruits. Diet supplementation by CGB of AFs-treated rats showed enhancement in final weight, food efficiency, and weight gain compared to AFs treatment only. Also, liver and kidney functions, liver enzymes, iron level, tumors indicator, and serum lipids of AFs- rats. Moreover, total protein, albumin, and globulin reduction by AFs have been improved by CGB presence in diets. Histopathological studies for AFs-rats liver showed dilated blood sinusoids with aggregation of inflammatory, Kupffer cell hyperplasia, degenerated hepatocytes, and apoptotic cells. However, in AFs-rat groups fed CGB in diets, liver hepatocytes appeared to be almost normal similar to the control. Results pointed out that CGB recorded a corrective action for aflatoxin B1 and G1 toxicity. This was recorded for the blood and serum parameters, and liver enzymes. This CGB action avoiding AFs-toxicity was more clearly declared in the liver tissues.

Correcting Judgment Correctives in National Security Intelligence.

Intelligence analysts, like other professionals, form norms that define standards of tradecraft excellence. These norms, however, have evolved in an idiosyncratic manner that reflects the influence of prominent insiders who had keen psychological insights but little appreciation for how to translate those insights into testable hypotheses. The net result is that the prevailing tradecraft norms of best practice are only loosely grounded in the science of judgment and decision-making. The "common sense" of prestigious opinion leaders inside the intelligence community has pre-empted systematic validity testing of the training techniques and judgment aids endorsed by those opinion leaders. Drawing on the scientific literature, we advance hypotheses about how current best practices could well be reducing rather than increasing the quality of analytic products. One set of hypotheses pertain to the failure of tradecraft training to recognize the most basic threat to accuracy: measurement error in the interpretation of the same data and in the communication of interpretations. Another set of hypotheses focuses on the insensitivity of tradecraft training to the risk that issuing broad-brush, one-directional warnings against bias (e.g., over-confidence) will be less likely to encourage self-critical, deliberative cognition than simple response-threshold shifting that yields the mirror-image bias (e.g., under-confidence). Given the magnitude of the consequences of better and worse intelligence analysis flowing to policy-makers, we see a compelling case for greater funding of efforts to test what actually works.

Three-year customer satisfaction survey in laboratory medicine in a Chinese university hospital.

BACKGROUND: Customer satisfaction is a key quality indicator of laboratory service. Patients and physicians are the ultimate customers in medical laboratory, and their opinions are essential components in developing a customer-oriented laboratory. METHODS: A longitudinal investigation of customer satisfaction was conducted through questionnaires. We designed two different questionnaires and selected 1200 customers (600 outpatients and 600 physicians) to assess customer satisfaction every other year from 2012 to 2016. Items with scores <4 were considered unsatisfactory, and corrective actions should be taken. RESULTS: The completion rates of physicians were 96.8% in 2012, 97% in 2014 and 96.5% in 2016, whereas the rates of patients were 95.3%, 96.2% and 95.2%, respectively. In 2012, the most dissatisfaction items were test turnaround time (3.77 points) and service attitude (3.87 points) from physicians, whereas waiting time (3.58 points) and examination environment (3.64 points) were the most dissatisfaction items from patients. After corrective actions were taken, the result of satisfaction in 2014 was better, which illustrated our strategy was effective. However, some items remained to be less than 4, so we repeated the survey after modifying questionnaires in 2016. However, the general satisfaction points of the physicians and patients reduced in 2016, which reminded us of some influential factors we had neglected. CONCLUSIONS: By using dynamic survey of satisfaction, we can continuously find deficiencies in our laboratory services and take suitable corrective actions, thereby improving our service quality.

A Toolkit for the Management of Protocol Deviations.

BACKGROUND: The DIA's Good Clinical Practice and Quality Assurance Community (DIA GCP/QA) created a working group to develop templates for a protocol deviation standard operating procedure (SOP) and protocol deviation handling plan (PDHP). METHODS: The working group consisted of QA auditors, data managers, statisticians, and clinical monitors from several pharmaceutical companies, academia, and independent auditing firms. Various examples of standard operating procedures, data handling plans, and auditing plans were examined, and the core elements extracted into the initial PD SOP and PDHP templates. The draft templates were presented at a workshop at the DIA 51st Annual Meeting held in June 2015 in Washington, DC, and feedback was incorporated. The workshop came at the heels of a previously published position paper, "The Lifecycle and Management of Protocol Deviations." RESULTS: The PD SOP and the PDHP templates are presented in this article. They are a starting point, and each company will need to modify to suit its individual needs. CONCLUSIONS: This article expands on the position paper to include concrete tools for the management of protocol deviations, including best practices for detection, classification, mitigation, and management of protocol deviations with a goal to reduce the impact on subject safety and data integrity.

Infusion pump-mediated mechanical hemolysis in pediatric patients.

CONTEXT: Hemoglobinuria was observed after packed red blood cell transfusion in a series of patients at our pediatric treatment center. Laboratory testing was suggestive of intravascular hemolysis with no support for an immunohematologic process. OBJECTIVE: We investigated these adverse events to define a quality improvement plan and to prevent future hemolytic adverse events. Multiple factors were investigated, and the only change identified was the implementation of a new infusion pump (Pump A) that replaced a previous model (Pump B). DESIGN: In vitro pump analyses, a retrospective review of urinalyses, and prospective urinalysis and nursing surveillances were also performed. RESULTS: In in vitro analysis of the pumps, irradiated units with higher hematocrit at a low flow rate through Pump A had a greater than thirty-fold increase in free hemoglobin from baseline compared to minimal free hemoglobin changes seen with Pump B. Irradiated units with a lower hematocrit had a minimal change in free hemoglobin from baseline with both Pumps A and B at either low or high flow rate. Subsequently, only units with lower hematocrits were issued for transfusion of pediatric patients, and Pump A was replaced by Pump B in the outpatient unit. Retrospective and prospective surveillances found no additional unexplained cases of gross hemoglobinuria associated with transfusion. CONCLUSION: The investigation determined that infusion of higher hematocrit units using a specific commercial pump was associated with mechanical hemolysis. The change to units with lower hematocrit through an alternative pump has been an effective corrective action to date.

The Life Cycle and Management of Protocol Deviations.

Clinical trials are designed to evaluate the efficacy, safety, or other characteristics associated with medical products. Trials are usually complex and require a large group of professionals to follow a clinical trial protocol, standard operating procedures, and study-specific manuals, guidelines, and plans. Clinical trial protocols prospectively describe the background and rationale for conducting the trial, the objectives of the trial, the trial design, the equipment to be used, the procedures to be performed, and the statistical methods on how the trial data are to be analyzed. Deviations from the protocol can result in harm to subjects, biased or inaccurate results, and possible rejection of all or part of the trial data by the sponsor or regulatory authorities. Despite preventive efforts, protocol deviations are likely to occur in most trials. This position paper proposes a common definition of protocol deviations and recommends best practices for their detection, classification, and management as part of their life cycle, with a goal of reducing their impact on subject safety and data integrity. The information contained herein is drawn globally from industry experts within the DIA Good Clinical Practice and Quality Assurance community, an industry-wide survey, and presentations with discussions at various industry meetings.

Role of a quality management system in improving patient safety - laboratory aspects.

OBJECTIVES: The aim of this study is to describe how implementation of a quality management system (QMS) based on ISO 15189 enhances patient safety. DESIGN AND METHODS: A literature review showed that several European hospitals implemented a QMS based on ISO 9001 and assessed the impact on patient safety. An Internet search showed that problems affecting patient safety have occurred in a number of laboratories across Canada. The requirements of a QMS based on ISO 15189 are outlined, and the impact of the implementation of each requirement on patient safety is summarized. The Quality Management Program - Laboratory Services in Ontario is briefly described, and the experience of Ontario laboratories with Ontario Laboratory Accreditation, based on ISO 15189, is outlined. RESULTS: Several hospitals that implemented ISO 9001 reported either a positive impact or no impact on patient safety. Patient safety problems in Canadian laboratories are described. Implementation of each requirement of the QMS can be seen to have a positive effect on patient safety. Average laboratory conformance on Ontario Laboratory Accreditation is very high, and laboratories must address and resolve any nonconformities. Other standards, practices, and quality requirements may also contribute to patient safety. CONCLUSION: Implementation of a QMS based on ISO 15189 provides a solid foundation for quality in the laboratory and enhances patient safety. It helps to prevent patient safety issues; when such issues do occur, effective processes are in place for investigation and resolution. Patient safety problems in Canadian laboratories might have been prevented had effective QMSs been in place. Ontario Laboratory Accreditation has had a positive impact on quality in Ontario laboratories.