Risk Management of Raw Materials

This paper discusses background information related to RM regulatory requirements and industry challenges, and then highlights key principles to consider in setting up a risk-based RM management approach and control strategy. This paper then provides an example of how to translate those key principles into a detailed RM risk assessment methodology, and how to apply this methodology to specific raw materials. To better illustrate the diversity and nuance in applying a corresponding RM control strategy, a number of case studies with raw materials typically utilized in the manufacture of biological medicinal products have been included as well as discussion on phase-based mitigations.
European Biopharmaceutical Enterprises (2018) “Management and Control of Raw Materials Used in the Manufacture of Biological Medicinal Products and ATMPs“

Good foundation document for how to build a risk management program for managing raw materials.

Review of Audit Trails

One of the requirements for data integrity that has changed in detail as the various guidances (FDA, MHRA, PIC/S) have gone through draft has been review of audit trails. This will also probably be one of the more controversial in certain corners as it can be seen by some as going beyond what has traditionally been the focus of good document practices and computer system validation.

What the guidances say

Audit trail review is similar to assessing cross-outs on paper when reviewing data. Personnel responsible for record review under CGMP should review the audit trails that capture changes to data associated with the record as they review the rest of the record (e.g., §§ 211.22(a), 211.101(c) and (d), 211.103, 211.182, 211.186(a), 211.192, 211.194(a)(8), and 212.20(d)). For example, all production and control records, which includes audit trails, must be reviewed and approved by the quality unit (§ 211.192). The regulations provide flexibility to have some activities reviewed by a person directly supervising or checking information (e.g., § 211.188). FDA recommends a quality system approach to implementing oversight and review of CGMP records.
US FDA. “Who should review audit trails?” Data Integrity and Compliance With Drug CGMP Questions and Answers Guidance for Industry. Section 7, page 8

If the review frequency for the data is specified in CGMP regulations, adhere to that frequency for the audit trail review. For example, § 211.188(b) requires review after each significant step in manufacture, processing, packing, or holding, and § 211.22 requires data review before batch release. In these cases, you would apply the same review frequency for the audit trail.If the review frequency for the data is not specified in CGMP regulations, you should determine the review frequency for the audit trail using knowledge of your processes and risk assessment tools. The risk assessment should include evaluation of data criticality, control mechanisms, and impact on product quality. Your approach to audit trail review and the frequency with which you conduct it should ensure that CGMP requirements are met, appropriate controls are implemented, and the reliability of the review is proven.

US FDA. “How often should audit trails be reviewed?” Data Integrity and Compliance With Drug CGMP Questions and Answers Guidance for Industry. Section 8, page 8

	Expectations	Potential risk of not meeting expectations / items to be checked
1	Consideration should be given to data management and integrity requirements when purchasing and implementing computerised systems. Companies should select software that includes appropriate electronic audit trail functionality. Companies should endeavour to purchase and upgrade older systems to implement software that includes electronic audit trail functionality. It is acknowledged that some very simple systems lack appropriate audit trails; however, alternative arrangements to verify the veracity of data must be implemented, e.g. administrative procedures, secondary checks and controls. Additional guidance may be found under section 9.9 regarding Hybrid Systems. Audit trail functionality should be verified during validation of the system to ensure that all changes and deletions of critical data associated with each manual activity are recorded and meet ALCOA+ principles. Audit trail functionalities must be enabled and locked at all times and it must not be possible to deactivate the functionality. If it is possible for administrative users to deactivate the audit trail functionality, an automatic entry should be made in the audit trail indicating that the functionality has been deactivated. Companies should implement procedures that outline their policy and processes for the review of audit trails in accordance with risk management principles. Critical audit trails related to each operation should be independently reviewed with all other records related to the operation and prior to the review of the completion of the operation, e.g. prior to batch release, so as to ensure that critical data and changes to it are acceptable. This review should be performed by the originating department, and where necessary verified by the quality unit, e.g. during self-inspection or investigative activities.	Validation documentation should demonstrate that audit trails are functional, and that all activities, changes and other transactions within the systems are recorded, together with all metadata. Verify that audit trails are regularly reviewed (in accordance with quality risk management principles) and that discrepancies are investigated. If no electronic audit trail system exists a paper based record to demonstrate changes to data may be acceptable until a fully audit trailed (integrated system or independent audit software using a validated interface) system becomes available. These hybrid systems are permitted, where they achieve equivalence to integrated audit trail, such as described in Annex 11 of the PIC/S GMP Guide. Failure to adequately review audit trails may allow manipulated or erroneous data to be inadvertently accepted by the Quality Unit and/or Authorised Person. Clear details of which data are critical, and which changes and deletions must be recorded (audit trail) should be documented.
2	Where available, audit trail functionalities for electronic-based systems should be assessed and configured properly to capture any critical activities relating to the acquisition, deletion, overwriting of and changes to data for audit purposes. Audit trails should be configured to record all manually initiated processes related to critical data. The system should provide a secure, computer generated, time stamped audit trail to independently record the date and time of entries and actions that create, modify, or delete electronic records. The audit trail should include the following parameters: – Who made the change – What was changed, incl. old and new values – When the change was made, incl. date and time – Why the change was made (reason) – Name of any person authorising the change. The audit trail should allow for reconstruction of the course of events relating to the creation, modification, or deletion of an electronic record. The system must be able to print and provide an electronic copy of the audit trail, and whether looked at in the system or in a copy, the audit trail should be available in a meaningful format. If possible, the audit trail should retain the dynamic functionalities found in the computer system, e.g. search functionality and export to e.g. Excel	Verify the format of audit trails to ensure that all critical and relevant information is captured. The audit trail must include all previous values and record changes must not obscure previously recorded information. Audit trail entries should be recorded in true time and reflect the actual time of activities. Systems recording the same time for a number of sequential interactions, or which only make an entry in the audit trail, once all interactions have been completed, may not in compliance with expectations to data integrity, particularly where each discrete interaction or sequence is critical, e.g. for the electronic recording of addition of 4 raw materials to a mixing vessel. If the order of addition is a CPP, then each addition should be recorded individually, with time stamps. If the order of addition is not a CCP then the addition of all 4 materials could be recored as a single timestamped activity.

PIC/S. PI 041-1 “Good Practices for Data Management and Data Integrity in regulated GMP/GDP Environments“ (3rd draft) section 9.4 “Audit trail for computerised systems” page 36

Thoughts

It has long been the requirement that computer systems have audit trails and that these be convertible to a format that can be reviewed as appropriate. What these guidances are stating is:

There are key activities captured in the audit trail. These key determined in a risk-based manner.
These key activities need to be reviewed when making decisions based on them (determine a frequency)
The audit trail needs to be able to show the reviewer the key activity
These reviews needs to be captured in the quality system (proceduralized, recorded)
This is part of the validated state of your system

So for example, my deviation system is evaluated and the key activity that needs to be reviewed in the decision to forward process. In this deviation decision quality makes the determination at several points of the workflow. The audit trail review would thus be looking at who made the decision when and did that meet criteria. The frequency might be established at the point of disposition for any deviation still in an opened state and upon closure.

What we are being asked is to evaluate all your computer systems and figure out what parts of the audit trail need to be reviewed when.

Now here’s the problem. Most audit trails are garbage. Maybe they are human readable by some vague definition of readable (or even human). But they don’t have filters, or search or templates. So companies need to be (again based on a risk based approach) evaluating their audit trails system by system to see if they are up-to-the-task. You then end up with one or more solutions:

Rebuild the audit trail to make it human readable and give filters and search criteria. For example on a deviation record there is one view for “disposition” and another for “closure”
Add reports (such as a set of crystal reports) to make it human readable and give filters and search criteria. Probably end up with a report for “disposition” and another report for “closure.”
Utilize an export function to Excel (or similar program)and use Excel’s functions to filter and search. Remember to ensure you have a data verification process in place.
The best solution is to ensure the audit trail is a step in your workflow and the review is captured as part of the audit trail. Ideally this is part of an exception reporting process driven by the system.

What risk based questions should drive this?

Overall risk of the system
Capabilities of audit trail
Can the data be modified after entry? Can it be modified prior to approval?
Is the result qualitative or quantitative
Are changes to data visible on the record itself?

Data Integrity and Control of Forms

In “Data Integrity and Compliance With Drug CGMP Questions and Answers Guidance for Industry” the FDA states the following about control of blank forms:

There must be document controls in place to assure product quality (see §§ 211.100, 211.160(a),211.186, 212.20(d), and 212.60(g)). For example, bound paginated notebooks, stamped for official use by a document control group, provide good document control because they allow easy detection of unofficial notebooks as well as any gaps in notebook pages. If used, blank forms (e.g., electronic worksheets, laboratory notebooks, and MPCRs) should be controlled by the quality unit or by another document control method. As appropriate, numbered sets of blank forms may be issued and should be reconciled upon completion of all issued forms. Incomplete or erroneous forms should be kept as part of the permanent record along with written justification for their replacement (see, e.g., §§ 211.192, 211.194, 212.50(a), and 212.70(f)(1)(vi)). All data required to recreate a CGMP activity should be maintained as part of the complete record.
6. How should blank forms be controlled? on page 7 of 13

First sentence “There must be document controls in place to assure product quality” should be interpreted in a risk based approach. All forms should always be published from a controlled manner, ideally an electronic system that ensures the correct version is used and provides a time/date stamp of when the form is published. Some forms (based on risk) should be published in such a way that contemporaneity and originality are more easy to prove. In other words, bind them.

A good rule of thumb for binding a printed form (which is now going to become a record) is as follows:

Is it one large form with individual pages contributing to the whole record that could be easily lost, misplaced or even intentionally altered?
Is it a form that provides chronological order to the same or similar pieces of information such as a logbook?
Is time of entry important?
Will this form live with a piece of equipment, an instrument, a room for a period of time? Another way to phrase this, if the form is not a once and done that upon completion as a record moves along in a review flow.

If you answer yes to any of these, then the default should be to bind it and control it through a central publishing function, traditionally called document control.

The PIC/S draft on data integrity has more to say here:

Reference	Expectation	Potential risk of not meeting expectations/items to be checked
Distribution and Control Item 2 page 17 of 52	Issue should be controlled by written procedures that include the following controls: – Details of who issued the copies and when they were issued. – using of a secure stamp, or paper colour code not available in the working areas or another appropriate system. – ensuring that only the current approved version is available for use. – allocating a unique identifier to each blank document issued and recording the issue of each document in a register. – Numbering every distributed copy (e.g.: copy 2 of 2) and sequential numbering of issued pages in bound books. Where the re-issue of additional copies of the blank template is necessary, a controlled process regarding re-issue should be followed. All distributed copies should be maintained and a justification and approval for the need of an extra copy should be recorded, e.g.: “the original template record was damaged”. – All issued records should be reconciled following use to ensure the accuracy and completeness of records.	Without the use of security measures, there is a risk that rewriting or falsification of data may be made after photocopying or scanning the template record (which gives the user another template copy to use). Obsolete version can be used intentionally or by error. A filled record with an anomalous data entry could be replaced by a new rewritten template. All unused forms should be accounted for, and either defaced and destroyed, or returned for secure filing.

Risk Management leads to Change Management, Change Management contains Risk Management

We did an FMEA for the design of the room. Why do we need a risk assessment for the change control to implement the design features?

We have an environmental risk management plan, including a HAACP. Why does this change control require a new risk assessment?

If I received a nickel……

I want to expand on my earlier thoughts on risk management enabling change.

Risk Management is a key enabler of any quality by design, whether of product, facility or equipment. We do living risk assessments to understand the scope of our ongoing risk. Inevitably we either want to implement that new or improved design or we want to mitigate the ongoing risks in our operation. So we turn to change management. And as part of that change management we do a risk assessment. Our change management then informs ongoing risk review.

Risk Management Leads to Change Management

Design Implementation

Through your iterative design lifecycle there is a final design ready for introduction. Perhaps this is a totally new thing, perhaps it is a new set of equipment or processes, or just a modification.

All along through the iterative design lifecycle risk management has been applied to establish measurable, testable, unambiguous and traceable performance requirements. Now your process engages with change management to introduce the change.

And a new risk assessment is conducted.

This risk assessment is asking a different question. During the interative design lifecycle the risk question is some form of “What are the risks from this design on the patient/process.” As part of risk management, the question is “What are the risks to SISPQ/GMP from introducing the change.”

This risk assessment is narrower, in that it looks at the process of implementing. Broader that it looks at the entirety of your operations: facility, supply chain, quality system, etc.

The design risk assessment and risk management activities informs the change management risk assessment, but it cannot replace them. They also can serve to lower the rigor of the change management risk assessment, allowing the use of a less formal tool.

Living Risk Reviews

risk leads to change

In the third phase of risk management – risk review – we confirm that the risks identified and mitigated as planned and are functioning as intended. We also evaluate to see if any additional, previously unpredicted risks have appeared. Risk review is the living part of the lifecycle as we return to it on a periodic basis.

From this will come new mitigations, targeted to address the identified risks. These mitigations inevitably lead to change management.

We again do a new risk assessment focusing on the risk of implementing the change. Informed by the living risk assessment, we can often utilize a less formal tool to look at the full ramifications of introducing the mitigation (a change).

Change Controls contains Risk Management

risk and change management connections

Effective change management is enabled by risk management.

Each and every change requires a risk assessment to capture the risks of the change. This ICHQ10 requirement is the best way to determine if the change is acceptable.

This risk assessment evaluates the impact on the change on the facility, equipment, materials, supply chain, processes. testing, quality systems and everything else. It is one of the critical reasons it is crucial to involve the right experts.

From this risk assessment comes the appropriate actions before implementing the change, as well as appropriate follow-up activities and it can help define the effectiveness review.

What about grouped change controls?

Depends. Sometimes the risk management looks at the individual implementations. Othertimes you need to do separate ones. Many times the risk assessment lead you to breaking up one change control into many. Evaluate as follows:

Are the risks from the separate implementations appropriately captured
Are the risks from pauses between implementations appropriately captured
As the ripples appropriately understood

Change Management Leads back to Risk Management

Sometimes a change control requires a specific risk assessment to be updated, or requires specific risk management to happen.

What about HAACP?

Hazard Analysis Critical Control Point (HACCP) are great tools for risk assessments. They are often the catalyst for doing a change, they are often the artifact of a change. They should never be utilized for determining the impact of a change.

A hazard is any biological, chemical, or physical property that impacts human safety. The HAACP identifies and establishes critical limits. But a HAACP is not the tool to use to determine if a change should move forward and what actions to do. It is to static.

In Closing

Risk Management is an enabler for change, a tenet enshrined in the ICH guidances. We are engaging in risk management activities throughout our organizations. It is critical to understand how the various risk management activities fit together and how they should be separated.

Contamination Control, Risk Management and Change Control

Microbiologists won’t be sequestered in the laboratory, running samples and conducting environmental testing, once the revisions proposed for Annex 1 of the EU and Pharmaceutical Inspection Cooperation Scheme (PIC/S) GMP guides take effect, Annex 1 rapporteur Andrew Hopkins said Oct. 15.

They will have a broader role that includes conducting risk assessments to ensure that sterile products are made as contamination-free as possible, said Hopkins, who is an inspector for the UK Medicines and Healthcare products Regulatory Agency.

Pink Sheet “EU GMP Annex 1 Would Give Microbiologists A Greater Role In Sterility Assurance, Rapporteur Says“

Contamination Control is a fairly wide term used to mean “getting microbiologists out of the lab” and involved in risk management and compliance. Our organization splits that function off from the QC Microbiology organization but there are many models for making it work.

Risk Management is a major part of the new Annex 1, and what they are driving at are good risk assessments with good risk mitigation that involve the microbiologists.

living risk assessments

This is really what is meant by a contamination control strategy which considers the product and process knowledge and skills in pharmaceutical product manufacturing and GMP/ cGMP compliance under the auspices of a Pharmaceutical Quality System (Q10) together with initiatives of Quality by Design (Q8) and Quality Risk Management (Q9).

From this strategy comes:

Targeted/ risk based measures of contamination avoidance
Key performance indicators to assess status of contamination control
A defined strategy for deviation management (investigations) and CAPA

environmental monitoring

When it comes to change management, one of the easiest places to go wrong is to forget to bring the microbiologist in to changes. Based on your strategy you can determine change changes require their assessment and include it in the tool utilized to determine SMEs, for example:

Department	Required if the change meets any of the following criteria:
Contamination Control	The change impacts environment integrity, conditions or monitoring, including: Changes to a controlled room or area that impact integrity Changes in sampling methodology Construction activities Changes in personnel or material flow The change will result in or modify exposure of product to the environment. The change can impact microbiological control within a process stream, raw material or process equipment The changes are to water systems

Department

Required if the change meets any of the following criteria:

Contamination Control

The change impacts environment integrity, conditions or monitoring, including:

Changes to a controlled room or area that impact integrity
Changes in sampling methodology
Construction activities
Changes in personnel or material flow
The change will result in or modify exposure of product to the environment.

The change can impact microbiological control within a process stream, raw material or process equipment

The changes are to water systems