Data Integrity for Record Management

Last night speaking at the DFW Audit SIG one of the topics I wished I had gone a little deeper on were controls, and how to gauge their strength.

As I am preparing to interview candidates for a records management position, I thought I would flesh out controls specific to the storage of and access to completed or archived paper records, such as forms, as an example.

These controls are applied at the record or system level and are meant to prevent a potential data integrity issue from occurring.

Generation and Reconciliation of Documents

	Data Criticality
	High	Medium	Low
Unique identifier	For each record	No	No
Who performs controlled issuance	Individuals authorized by quality unit from designated unit (limited, centralized)	Individuals authorized by quality unit from (limited, decentralized)	Anyone (unlimited, decrentalized), often user of record
Reconciliation	Full reconciliation of record and pages based on unique identifier	Full reconciliation of records and pages based on quantity issued	No reconciliation
Controlled print	Yes	Yes	No
Bulk printing	No	Yes, by controlled process	Yes
Destruction of blank forms	Performed by issuing unit, quality oversight required (High level of evidence)	Performed by the operating or issuing unit, quality unit oversight required	Performed by the individual, quality unit oversight required (periodic walk throughs, self-inspections and audits)

Storage and Access to completed and archived paper records

	Data Criticality
	High	Medium	Low
Where Stored	Climate-controlled room	Climate-controlled room	Office retention location
How Removed & Returned	Limited conditions for removal (e.g. regulatory inspections) method of recording the removal and return of the record(e.g. archive management system, logbook). Most use of documents either in controlled reading area or by scans.	Method of recording the removal and return of the record(e.g., archive management system, logbook).	Method (e.g. logbook) recording of documents checked-in/checked-out
Access Control	Card key access with entry and exit documented.	Card key access with entry and exit documented.	Limited key access
Periodic User Access Review	Annually	Annually	Every 2 years

There are also the need to consider controls for paper to electronic, electronic to paper and my favorite beast, the true copy.

For paper records a true copy of a picture of the original that keeps everything – a scan. The regulations state that you can get rid of the paper if you have a true copy. Many things called a true copy are probably not a true copy, to ensure an accurate true copy add two more controls.

	Data Criticality
	High	Medium	Low
Review requirements	Documented review by second person from the quality unit for legibility, accuracy, and completeness	Documented review by second person (not necessarily from the quality unit) for legibility, accuracy, and completeness	Documented verification by person performing the scan for legibility, accuracy, and completeness
Discard of original allowed	Yes, as defined by quality unit oversight, unless there is a seal, watermark, or other identifier that can’t be accurately reproduced electronically.	Yes, performed by the operating unit, unless there is a seal, watermark, or other identifier that can’t be accurately reproduced electronically. Quality unit oversight required	Yes, individual can discard original Quality unit oversight required

OOS failures

Go and read the January 2021 FDA warning letter to Allay Pharmaceuticals and then go and read the 1993 decision in United States vs Barr Laboratories.

The Barr decision, issued 28 years ago, explains how to deal with OOS results. The FDA followed up with a guidance in 2006 “Guidance for Industry Investigating Out-of-Specification (OOS) Test Results for Pharmaceutical Production.” Companies have no excuse for continued failure here, and yet as we see with Allay (and so many others) failures in investigation of out-of-specifications continues to be a major concern. Yet nothing we see is not covered in the Barr decision.

If you a pharmaceutical GMP professional these three documents should be ones you are more than ready to explain against your quality system.

Upcoming Data Integrity Virtual Presentation

I will be presenting at the February Audit SIG of the DFW Section of the ASQ on Data Integrity. Many companies struggle with the concepts of data integrity as it involves both paper and electronic data, dealing with legacy computer systems and the organization culture. This session will lay out the core principles of data integrity:

Organizational culture should drive ALCOA
Data governance is part of the management review process
Data Risk Assessments with appropriate mitigations (full risk management approach)

The Audit SIG webinar is scheduled for Tuesday February 9, 2021 at 6:00 pm. To sign up RSVP to jcapstick@gramercyinc.net by February 8 by 6:00 pm. An email with a link to the webinar will be returned to those that RSVP.

Root Cause Analysis Deficiencies

An appropriate level of root cause analysis should be applied during the investigation of deviations, suspected product defects and other problems. This can be determined using Quality Risk Management principles. In cases where the true root cause(s) of the issue cannot be determined, consideration should be given to identifying the most likely root cause(s) and to addressing those. Where human error is suspected or identified as the cause, this should be justified having taken care to ensure that process, procedural or system based errors or problems have not been overlooked, if present.
Appropriate corrective actions and/or preventative actions (CAPAs) should be identified and taken in response to investigations. The effectiveness of such actions should be monitored and assessed, in line with Quality Risk Management principles.
EU Guidelines for Good Manufacturing Practice for Medicinal Products for Human and Veterinary Use, Chapter 1 Pharmaceutical System C1.4(xiv)

The MHRA cited 210 companies in 2019 on failure to conduct good root cause analysis and develop appropriate CAPAs. 6 of those were critical and a 100 were major.

My guess is if I asked those 210 companies in 2018 how their root cause analysis and CAPAs were doing, 85% would say “great!” We tend to overestimate our capabilities on the fundamentals (which root cause analysis and CAPA are) and not to continuously invest in improvement.

Of course, without good benchmarking, its really easy to say good enough and not be. There can be a tendency to say “Well we’ve never had a problem here, so we’re good.” Where in reality its just the problem has never been seen in an inspection or has never gone critical.

The FDA has fairly similar observations around root cause analysis. As does anyone who shares their metrics in any way. Bad root cause and bad CAPAs are pretty widespread.

This comes up a lot because the quality of CAPAs (and quantity) are considered key indicators of an organization’s health. CAPAs demonstrate that issues are acknowledged, tracked and remediated in an effective manner to eliminate or reduce the risk of a recurrence. The timeliness and robustness of these processes and records indicate whether an organization demonstrates effective planning and has sufficient resources to manage, resolve and correct past issues and prevent future issues.

A good CAPA system covers problem identification (which can be, and usually is a few different processes), root cause analysis, corrective and preventive actions, CAPA effectiveness, metrics, and governance. It is a house of cards, short one and the whole structure will fall down around you, often when you least need it to.

We can’t freeze our systems with superglue. If we are not continually improving then we are going backwards. No steady state when it comes to quality.

MHRA 2019 GMP Inspection Data and Documentation observations

Transparency is something that regulatory agencies need to get better at, both in sharing more and doing it in a timely manner. The fact that the 2019 data from the MHRA was released in October of 2020 is pretty poor. As a reference, the FDA releases their data pretty reliably at the end of the calendar year for the given year.

Been evaluating the MHRA’s 2020 data on Chapter 4 Documentation, which is the 2nd largest category of observations in 2019 (and in 2018 before it).

80 different inspections cited comments against the Principles section

Good documentation constitutes an essential part of the quality assurance system and is key to operating in compliance with GMP requirements. The various types of documents and media used should be fully defined in the manufacturer’s Quality Management System.

Documentation may exist in a variety of forms, including paper-based, electronic or photographic media. The main objective of the system of documentation utilized must be to establish, control, monitor and record all activities which directly or indirectly impact on all aspects of the quality of medicinal products. The Quality Management System should include sufficient instructional detail to facilitate a common understanding of the requirements, in addition to providing for sufficient recording of the various processes and evaluation of any observations, so that ongoing application of the requirements may be demonstrated.

There are two primary types of documentation used to manage and record GMP compliance: instructions (directions, requirements) and records/reports. Appropriate good documentation practice should be applied with respect to the type of document.

Suitable controls should be implemented to ensure the accuracy, integrity, availability and legibility of documents. Instruction documents should be free from errors and available in writing. The term ‘written’ means recorded, or documented on media from which data may be rendered in a human readable form.
Principles, Chapter 4 Documentation

The Principles section then goes on to lay out the required document types.

I would love to see more. Is this 80 companies who don’t known what a SMF is? Good documentation practices? Don’t have SOPs and batch records? Have errors in their documents? Don’t approve them? More transparency would be valuable here.

We can learn more by drilling down in the document.

There are 87 inspections with 4.1 in section “Generation and Control of Documents”. 1 is critical and 25 are major. Here we see failures in understanding types of documents and controlling them, or maybe just having them in the first place.
The 82 against 4.2 (1 critical and 20 major) are more about having the manufacturing and testing process defined (and matching the filing).
103 inspections with observations against 4.3 (23 major) show companies that do not have appropriate approval and release controls
14 for 4.4 (6 major) means there are 14 companies out there who can’t write a good process and procedure. 4.4 has one of my favorite requirements “written in an imperative mandatory style”
60 against 4.5 (13 major) demonstrates a lack of review and keeping documents up-to-date.
12 companies (6 major) have terrible handwriting and cannot stick to ballpoints, yes in fact 4.7 states “Handwritten entries should be made in clear, legible, indelible way.”
103 against 4.8 (1 critical and 28 major) is ALCOA focused on contemporaneous, attributable and accurate.
18 for 4.9 (6 major) is for not correcting data correctly. That’s right 18 companies do not know how to comment correctly.
22 for 4.10 (1 critical and 9 major) is for not clearly laying out the manufacturing records and keeping them for the retention period.
19 for 4.29 (5 major) is a lack of process and procedure for a grab-bag of quality processes from change control to equipment management to cleaning

There are more, but we are in single digit observation territory.

Useful things to be evaluating in your own organization. As a good place to start, here are some questions to ask when contemplating data integrity.