Department Micro Laboratory Document no MICLAB 145 Title 1.0 DOCUMENT OWNER Laboratory/Quality Manager 2.0 PURPOSE To establish a procedure for the investigation of initial out-of-specification (OOS) or questionable results which have been generated for the product or material being tested. 3.0 SCOPE Initial Investigation of Out of Specification (OOS) Results in Microbiological Laboratory Prepared by: Date: Supersedes: Checked by: Date: Date Issued: Approved by: Date: Review Date: 3.1 This procedure applies to test results generated for raw materials, in-process materials, stability and finished products tested for medicinal products for commercial sale. 3.2 This procedure applies to test results generated for release, stability, in-process and retained samples associated with a complaint investigation. 3.3 This procedure does not apply to results generated by testing not described in 3.1 or 3.2 or out of specification results for process water and environmental samples. 3.4 An investigation for out-of-specification or questionable results must be initiated when an analysis has been performed on the sample in question. 3.5 Instances of out-of-specification or questionable results, where assignable cause is not readily apparent shall be investigated in accordance with the requirements described in this procedure. 3.6 If assignable cause is readily apparent, the occurrence is documented using the Laboratory Investigation Report (LIR) form, as applicable. 3.7 All LIR s must be completed and fully approved within 30 business days of the discovery of the initial OOS or questionable result. If laboratory investigation goes beyond 30 business days, an interim status report must be issued to the QA Manager. 3.8 All LIR s should be reviewed once per year to determine if trends are observed that require further action strictly prohibited. Page 1 of 11
4.0 RESPONSIBILITY \ BUSINESS RULES 4.1 Quality Assurance Manager is responsible for: - Reviewing laboratory investigations and considering in batch/lot release decisions. - Approval re-sampling programs of materials for use in the laboratory investigation. - Issuing Action reports to appropriate personnel when deemed necessary. - Evaluate the need for investigations where confirmed out-of-specification results occur and ensuring they are completed. - Approving laboratory investigations on completion. 4.2 Laboratory Manager is responsible for: - Ensuring that this SOP is understood and adhered to by all laboratory personnel. - Establishing and maintaining a log of all laboratory reports. - Where appropriate notifying the QA Manager to instigate further investigation where confirmed out-of-specification results are produced. - Reports trends of Microbiology Laboratory Investigations to the QA Manager on a periodic basis. - Complete final review of the Laboratory Investigation Report. - Review LIR s once a year, observe trends and take action if applicable. 4.3 Microbiology Team Leader is responsible for: - Reviewing and approving the applicable sections for the laboratory investigation report. - Approving investigation measurements and re-testing plans. - Ensuring laboratory investigation reports, all results and laboratory records are achieved. - Responsible for closing out LIR in database for tracking and trending purposes. - Responsible for circulating the Alert Reports. - Assisting the Laboratory Analyst in the completion of the Microbiology Laboratory Investigation Report. 4.4 Microbiological Analyst: - Immediately notifying the Microbiology Team Leader or Laboratory Manager of any out-ofspecification or questionable result. - Initiating and assisting in the completion of the Laboratory Investigation Report. - Including all data generated in the laboratory investigation report. strictly prohibited. Page 2 of 11
- Immediately notifying the Microbiology Team Leader or the Lab Manager of any microbiological test result which does not meet specification or which fits the description of a questionable test result. 5.0 PROCEDURE 5.1 Discovery of out-of-specification or questionable result. 5.1.1 Upon discovery of any OOS or Questionable Result, the Lab Analyst shall immediately, before initiating any repeat testing, or retesting take the following actions: report the results to the Lab Team Leader or Lab Manager; document findings; document obvious errors (e.g., spilling of solutions or incomplete transfer of sample or standard), if known; retain all original samples and test preparations, such as sample solutions, standard solutions, glassware, microbiological culture media, and reagents used in the analysis and subsequent investigation, to the extent possible, until the initial investigation is completed; and retain samples and associated test preparations, when possible, in a manner that ensures their integrity (e.g., refrigerated) until the test article receives a final disposition. Note: The Lab Team Leader shall determine if obvious errors (e.g., calculation or dilution errors) exist that might have caused the OOS or Questionable Result. If an obvious error is found, the OOS or Questionable Result is considered an invalidated result and no further investigation is required, unless the error would impact other testing. If obvious errors are not found, the Lab Team Leader shall initiate a further investigation. 5.1.2 The analyst ensures that an entry into the laboratory investigation database (online) or if this database is not available, an entry into the log book (manual system) is made and that a unique number is assigned to the laboratory investigation report. At this time, the analyst and team leader or designate completes section 1 (general information) of the laboratory investigation report. In cases where more than one lot of material is investigated for the same problem, only one investigation report is required. All affected lots must be clearly listed. 5.1.3 All Laboratory Investigation Reports are assigned a unique number. In cases where the online system is used, the number is assigned automatically by the database system and is denoted by the following format: (YYYYMMXXX, where YYYY and MM are representative of the computer system date s year and month respectively and XXX is uniquely allocated a sequential number applied based on the month and year. strictly prohibited. Page 3 of 11
In cases where a manual system is used, the number consists of a two-letter prefix (LI) followed by an eight-digit identification number. The format of the Laboratory Investigation Report number will be as follows: The first two digits of the identification number are the Department Number for the Laboratory in which the investigation was conducted. The department numbers are as follows: 10 = Analytical Services, 23 = Quality Control & Microbiology, 41 = Research & Development. The second two digits of the identification number indicate the year in which the Laboratory Investigation was conducted. The remaining four digits are assigned sequentially from the Laboratory Investigation log book for that laboratory with the numbering system starting anew at the beginning of the year. 5.2 Initial Investigation. 5.2.1 Within one business day, the analyst and the microbiologist must initiate a Microbiological Laboratory Investigation, completing the following sections of the Laboratory Investigation Report. Section I: Purpose of Investigation Section II: Reason For Investigation Section III: Initial Investigation Section IV: Findings/Conclusions from initial investigation All sections must be completed with appropriate detail to fully describe steps taken. If a section is considered not applicable to the investigation, i.e. assignable cause is readily apparent, mark the section "Not Applicable". Justification must be provided in Section IX: Overall conclusion from III, IV, V (if applicable), VI, VII. 5.2.2 After opening the LIR, the initial investigation to determine assignable cause begins when the Micro Team Leader holds discussions with the Lab Analyst and completes the LIR Form Section I General Information. Section I shall include a clear and concise description of the reason for the investigation. In cases where more than one lot of material is investigated for the same problem, only one LIR is required. All affected lots must be clearly listed. The initial investigation also includes but is not limited to examinations of the following (LIR Form Section II, Review of Testing Parameters ): Test records (raw data and/or laboratory notebooks); Test procedures used; Calculations; Dilution schemes; Instrumentation or equipment functionality; Reference Standards, reagents, and media used; Sample preparations; and Personnel training and qualifications. strictly prohibited. Page 4 of 11
5.2.3 If, in the Micro Team Leader s judgement, assignable cause is identified for an OOS or questionable result, the original result is invalidated. The assignable cause shall be documented in the LIR Form Section III Initial Investigation and Section IV Findings/Conclusions from Initial Investigation within one business day of discovery of the result. Testing is then repeated to generate valid results. 5.3 Assignable Cause. 5.2.3.1 The analyst completes Section VII of the Laboratory Investigation Report: Retest Protocol. The Microbiology Team Leader approves the retest protocol. Retest is conducted as per the approved protocol. The OOS or Questionable Result may be accepted as valid following the initial investigation with no further retesting. If there is no readily apparent assignable cause the investigational measurement protocol (IMP) (section V of the laboratory investigation report) is prepared and signed by the team leader or designate. The purpose of conducting investigational measurement is to determine an assignable cause. This section should only be completed when a suitable protocol is decided. Data generated during and investigational measurement is for investigation only and shall not be used as a valid test result. 5.2.3.2 On the Laboratory Investigation Report, the Micro Team Leader delegate/ completes Section VIII: Results of Retest, Section IX: Overall Conclusions and if corrective action is required, Section X: Corrective Action Plan. The potential impact on other samples tested during the initial testing must be evaluated when an assignable cause is found. All related test results must be assessed for validity. A statement documenting the assessment and the decision must be included on the LIR Form Section III Review of Testing Parameters, or Section IV Findings/Conclusions from Initial Investigation. 5.2.3.3 If, in the Lab Manager s judgment, no readily apparent assignable cause is determined by the initial investigation, it may be necessary to issue an Alert report to notify others of the situation. The Lab Manager shall determine whether an alert report is needed and notify the QA Manager that an alert report is needed. The QA Manager shall ensure that such reports are issued within one business day following the completion of Section IV of the LIR form. 5.3.1 Test Results, whether In- or Out-of-Specification, that are obtained under the following conditions must be invalidated and the test repeated. These are examples of the classifications that are included on the LIR Form to document types of assignable causes: Sample The original sample was contaminated or insufficient in quantity; Method/Documentation Unclear test method for Standard Operating Procedure directions which resulted in incorrect test execution; Analyst Error Examples include, but are not limited to: strictly prohibited. Page 5 of 11
- incorrect sample quantity used; - sample, sample solution, or standard spills; - dilution errors; or - improper test procedure; and Instrument/Mechanical/System Malfunction eg incubators. 5.4 Repeating the test (Assignable Cause Identified). All tests that were invalidated by establishment of an assignable cause are repeated. The repeat test result(s) shall replace the original invalidated results only. The original sample preparation(s) shall be used for this testing if: there is sufficient quantity of sample remaining to repeat the test; the assignable cause was not due to sample preparation; the sample preparations are stable and maintained under proper environmental conditions; and the sample or the sample preparations are not inadvertently contaminated. 5.4.1 LIR form Section VII Retest Protocol and Section VIII results of retest shall be used to document the repeat tests and the results obtained. The repeat /retest protocol shall be approved by Micro Team Leader prior to any repeat testing. 5.4.2 Microbial Limits Testing may be repeated for OOS or Questionable Results, using a 25gram sample for solids or 25 ml for liquids. 5.5 Retesting (No Assignable Cause Identified). 5.5.1 A Retest Protocol LIR Form Section VII Repeat /Retest Protocol shall be approved by the Lab Team Leader prior to any retesting. 5.5.2 The retest protocol must be based on the specific problem identified, the history of the product, method, and batch/lot, any applicable compendial requirements, and must delineate the number of retests to be performed. 5.5.3 Where sample is available, retesting must be executed using the same sample set that was the source of the original OOS or Questionable Result, unless there is scientific rationale for not using the same sample. The rationale must be documented. 5.5.4 A control lot may be used to verify the accuracy of the analyses. The retest plan must specify acceptance criteria for the control lot. 5.6 Resample. 5.6.1 If evidence is provided that the original sample was contaminated, the material is re-sampled per approved sampling procedures and approval is required by QA Manager. If the approved sampling procedure is found to be the cause, an investigation must be initiated to assess the impact of the defective sampling technique on other batches. strictly prohibited. Page 6 of 11
5.6.2 Obtaining additional stability samples is permitted for confirmatory purposes. However, when possible, the sample that was the source of the initial OOS or Questionable Result must also be included in the retest plan. 5.6.3 All stability samples from the same packaging lot and stored under identical conditions are considered equivalent for the resample purposes. 5.7 Evaluation of results. 5.7.1 If an assignable cause is associated with the original OOS or Questionable Result, the original result is invalidated and the impact of the assignable cause on other samples in the test must be determined. 5.7.2 Data from the original sample shall be retained in the test record, invalidated, and not included in the batch disposition decision when an assignable cause has been established. 5.7.3 If no assignable cause is found to be associated with the original OOS, and retesting is performed, all test results shall be documented on the LIR, forwarded to the QA Manager, and considered in batch/lot release decisions. 5.7.4 If the test method is shown by investigation to be in question, a general review of the method must be conducted, and required corrective action taken. Corrective action is to be recorded on the LIR form. 5.8 Reporting Results. 5.8.1 Invalidated OOS Results shall not be averaged with retest results for reporting purposes. 5.8.2 LIR Form Section VIII Repeat/Retest Results shall be used to report results [i.e., the value determined to be the final valid results (e.g., the retest results, or the confirmed initial OOS)]. 5.8.3 Upon completion of the Laboratory Investigation for initial OOS results, the Laboratory Manager determines if the QA Manager needs to issue an Alert report. 5.8.4 A confirmed OOS microbiological test result shall result in rejection of the test article. 5.8.5 In the event of a confirmed OOS Result, it may be necessary to issue an alert report to other departments within the site to notify them of the situation. The QA Manager shall ensure that such reports are issued within one business day following confirmation of an OOS Result. The QA Manager shall also evaluate the need for an investigation into the source of the confirmed OOS result and ensure that such investigations are completed. 5.8.6 The QA Manager shall inform the Senior Management Team (QO Manager, Production Manager and the Operations Director) which shall determine if the issuance of any reports responsible for notifying the Area Quality Review Team (A-QRT) in the event of any proposed market Action (eg. Product Recall) or stop distribution notice. 5.9 Closing the Laboratory Investigation. strictly prohibited. Page 7 of 11
5.9.1 LIR Form Section IX Overall Conclusions, and if relevant, Section X Corrective Action Plan, shall be completed by the Lab Team Leader. 5.9.2 The Lab Manager and the QA Manager, using LIR Form Section XI Laboratory Investigation Report Approval, shall approve the completed LIR. 5.9.3 All LIRs must be completed and fully approved within 30 business days of the discovery of the initial OOS or Questionable Result. If the Laboratory Investigation will go beyond 30 business days, an interim status report must be issued by the Lab Manager to the QA Manager containing at least the following: The date of discovery of the OOS or Questionable Result, Summary of the LIR general information, Reason for the delay, Current status of the investigation, and Estimated date for completion of the LIR. 5.9.4 The Approved LIR shall be: considered part of the batch record; distributed as per Site procedures; and retained by the QA according to record retention policies. 5.9.5 LIR will be reviewed by the QA and QC Manager at least once per year to determine if trends are observed that require further corrective action. strictly prohibited. Page 8 of 11
LI Process Flowchart OOS or Questionable Result Detected Laboratory Team Leader Notified and LIR Raised if required NOTE 1: At any time during the LI, QA Manager may issue Alerts to principals potentially affected SEEK ASSIGNABLE CAUSE (AC) Review for obvious errors NOTE 2: Following Initial Investigation, the OOS or Questionable Result may be accepted as valid with no further investigational measurement or testing. AC Found? Yes Take Corrective Action No Conduct Initial Investigation Declare Original Results invalid AC Found? No Yes Repeat tests to replace initial result Is Resample needed? No Retesting Establish Retest Protocol and conduct retest Yes OOS Confirmed? No Report all test results to the QA Manager Obtain QA manager approval for resampling Yes QA Manager issues all required Alerts; and initiates any further required investigations Complete & Close LIR Form strictly prohibited. Page 9 of 11
6.0 DEFINITIONS / ACRONYMS 6.1 Microbiological Laboratory Investigation: The means by which the laboratory personnel document and investigate test results that do not conform to a predetermined specification or are questionable. The information is documented in a Microbiological Laboratory Investigation Report. The investigation shall be initiated when a questionable result or an Out of Specification (OOS) result has been identified. 6.2 Assignable Cause: The documented and scientifically justified explanation of the reason for an out of specification or questionable result. This is determined only after conducting a Microbiological Laboratory Investigation. 6.3 Assessment of Microbiological Contamination: In situations where raw material or finished product specifications are not clear as to whether an organism is objectionable, the significance of the micro -organism shall be assessed relative to the end product use, the nature of the product, and the potential hazard to the user. 6.3.1 The significance of the micro organism(s) isolated must be assessed encompassing the below listed criteria: 6.4 Questionable Result: The end product use. Nature of the finished product. Potential hazard to the user. Route of administration. Ability of the organism to degrade the product. Capacity of the product to support growth of the organism. Unusual or aberrant test results which do not involve an out of specification result. Examples of questionable results in a Microbiology Laboratory include: 6.4.1 A pour plate method for determining the total aerobic microbial count using duplicate plates exhibited colonies on one plate in numbers that suggested the duplicate plate may not have contained the sample inoculum preparation. 6.4.2 Microbial Identification System identifies an organism for which an expected identification is not supported by the initial Gram stain morphology and confirmatory testing, or the probability of the identification based on the statistical confidence in the identification may be considered questionable and in need of further evaluation. strictly prohibited. Page 10 of 11
6.4.3 When serial dilutions are plated, higher number of CFU's are recovered from higher dilutions. 6.4.4 Micro-organism recovery is obtained on selective medium but no growth is obtained on non-selective medium, both coming from the same broth preparation. 6.5 Resample: A new sample obtained from previously sampled batch. 6.6 Retest: Additional testing on the original test sample. Re-testing is only appropriate after a Microbiological Laboratory Investigation has been completed, and where an assignable cause has been identified for an OOS result during a Microbiological Laboratory Investigation. 6.7 Out of Specification Result: A single determination of a test sample that does not conform to established specification. 6.8 Analyst Error Situations where OOS or questionable data are the result of a failure to comply with the approved procedure or an error during the analysis. Examples include the following; improper test procedure, contamination through the use of non-sterile equipment, media, diluents etc. 7.0 RELATED DOCUMENTS Form 690 Laboratory Investigation Report Form 8.0 SUMMARY OF CHANGES Version # MicLab-150 Revision History New strictly prohibited. Page 11 of 11