SOP on Handling of Deviations

 Pharmaceutical Guidanace  April 2, 2016  QA & QC, Quality Assurance, SOP  3,102 Views

SOP on Handling of Deviations

Objective :To describe a procedure for handling of deviations which may occur during the execution of

various activities in written procedures in facility.

Scope:This Standard Operating Procedure shall be applicable to all the departments responsible for
carrying activities related to the manufacture of the product, in the formulation plant of (Pharmaceutical

Company Name).

Responsibility

Personnel of concerned department shall be responsible to notify immediately their respective superiors

when any deviation occurs or is noticed.

Head-Regulatory Affairs or his/her designee shall be responsible for facilitating prior notification or
intimation to the regulatory authority, if the deviation has impact on the concerned regulatory

submissions.

Head of the concerned department or his/her designee, and Head-Quality Assurance or his/her
designee of respective location shall be responsible for implementation and compliance of this SOP.

Accountability

4.1 QA Head shall be accountable for implementation of this SOP.

Abbreviations and Definitions

BMR:Batch manufacturing record; a controlled regulated copy, which comprises the recordings against the

manufacture of a batch.

PDR :Planned deviation report

UDR :Unplanned deviation report

cGMP:Current good manufacturing practices

BPR:Batch packing record

ICH:International conference on harmonization

Written Procedures :Written procedures are the approved and controlled documents which are followed for

the execution of various activities performed in the organization viz.,Batch Manufacturing Records detailing

manufacturing and packaging procedures, Standard Operating Procedures (SOPs), Standard Testing

Procedures (STPs). General Test Procedures and various protocols followed for the execution of validation
studies, stability studies, etc.

Deviation : Any non-conformance /disobeyance in written approved procedures of quality system in the

organization.

Or

We have any written procedure like standard operating procedure, standard test procedure, BMR etc. and

works against this, then it is called deviation. It means deviation from any written procedure that we have
implemented.

Critical Deviation: The deviation is likely to or will have a significant impact on critical attributes of the

product.

For example: Manufacturing instructions are not followed, wrong batch details are printed, SOPs or
methods of testing not followed during analysis etc.

Major Deviation : The deviation could or may have a significant impact on critical attributes of the
product.

For example: Raw material is received in a damaged container, manometer readings in the sampling

booth are crossed the action limits etc.

Minor Deviation:The deviation is unlikely to have a detectable impact on critical attributes of the product.

For example: Line Clearance is not taken from QA, physician sample wrongly printed with price, etc.

Critical Attribute :A critical attribute is one that defines the product and contributes to safety, identity,

purity, strength or quality. Critical attributes are usually detectable during product testing.

Unplanned Deviation: An accidental or unanticipated non-conformance or deviation observed or noticed

during or after the execution of an activity. An unplanned deviation can be a critical or major or minor in

nature.

For example: deviation in failure of procedure, utility, material, equipment or any system is occurred. We can
consider it as any change from the previous or our written procedure.

Planned Deviation : Any deliberate or intentional non-conformance or deviation Planned prior to the

execution of an activity, which is to be undertaken following documented, justifiable and approved rationale.
No critical or major deviation, which has potential to alter the quality of the product, shall be planned.

For example: Calibration or validation is not carried out as per schedule due to delay for various reasons.

 Procedure

Deviations may be classified into following two categories:

Planned Deviation

Un-planned Deviation

Unplanned & Planned deviations shall be sub classified on the basis of their impact of product quality in
critical, major or minor.

Planned Deviation (Planned Deviation Report)

Any departure from established and approved procedures observed or noticed prior to the execution of
an activity, such as SOPs, STPs, processes, systems, standards and protocols, which is done under
compulsion or for continuous quality improvement programs will be categorized as planned deviation.

No critical or major planned deviation shall be allowed, which has potential to alter the quality of the
product, only minor deviation shall allow to plan.

Such a planned deviation shall be taken / implemented only after proper evaluation, risk assessment and

pre-approval from Quality Assurance.

Such planned deviation shall be properly reported, assessed / evaluated for its impact on product quality,
process performance or GMPs.

Any personnel from concerned department shall initiate the “Planned Deviation Format” by detailing the

reason for deviation as per Annexure I.

The department head shall review the proposal of planned deviation, justification given for its potential
impact on the product quality and compliance to regulatory requirements for necessity / feasibility of the

deviation, by providing supporting data.

After review by concerned Head of department, the proposal shall be forwarded to Plant Head.

After review by Plant Head, the proposal shall be forwarded to QA for review and approval.

QA shall assign a unique number to each planned deviation as follows:

The numbering system for a planned deviation shall consist of ten (10) alphanumeric characters.

For example, PDR/16/001 shall be assigned to the first planned deviation of year 2016.

In the above planned deviation report number, the 1st, 2nd & 3rd characters ‘PDR’ stand for ‘Planned
Deviation Report’.

The 4th character “/” is a forward slash.

The 5th & 6th characters ‘16’ represent the last two digits of the year 2016.

The 7th character “/” is again a forward slash.

The 8th, 9th & 10th characters ‘001’ represent sequential number.

Head QA shall review the planned deviation with respect to impact on product quality, necessity /

feasibility of the deviation proposed, rationale / justification & compliance to cGMP / regulatory

 requirements, along with the adequacy of the supporting data attached.

Head QA shall assess the requirement for any additional testing or checks for quality monitoring of the

Planned Deviation and documents for the same.

QA shall consult Regulatory Affairs, where applicable, for any planned deviation before providing
approval. The RA may provide inputs as necessary based on GMP and regulatory requirements.

Head QA shall approve / reject the Planned Deviation with appropriate recommendations.

If approved, the deviation shall be applicable for a defined number of batch (es) or defined number of
days as mentioned in the Planned Deviation Report.

After QA approval, the concerned department shall implement the planned deviation and the

observations and data generated shall be documented.

QA shall review the implementation and documented data obtained from respective departments to

ensure that the recommendations are complying with quality profile of the batch (es) impacted by the

deviation. This data shall support with the “Planned Deviation Report”.

The closure of planned deviation shall be the responsibility of the Department Head and Head-QA.

If the deviation is related to the batch which is for sale, then the batch shall be released only after QA
approval and closure of deviation.

Recommendations may be conferred during the review.

If the planned deviation in the process / procedures leads to improvement in the product quality /
process / assurance / GMP, then the deviation / change can be made permanent by following the change

control procedure (SOP on change control procedure).

In conclusion, Head of concerned department and Head QA shall close out the deviation.

QA shall maintain a logbook for the approved planned deviations as per Annexure III.

Unplanned Deviation (Unplanned Deviation Report)

While carrying out day-to-day activities, there is a probability of unplanned deviations (unforeseen
deviations) occurring. Such unexpected events may be related to any procedures, processes, systems,

equipment and utilities. These deviations may occur for many reasons, such as following (not all

inclusive):

Equipment failure / Breakdown / Malfunctioning.

Power supply failure / interruption.

Accident in the plant.

Breakdown in support services / utilities.

Documentation Errors

Laboratory failure / Error.

An unplanned deviation report (UDR) shall be initiated as a part of the approved system for handling of

deviations, in order to provide a mechanism for ensuring the recording of the deviation and assess the 
impact on product quality. If required, corrective and preventive action shall be performed to ensure

product quality.

User department shall make request for issuance of unplanned deviation Format to Quality Assurance

department through Issuance from.

Any individual on the job shall inform concerned department supervisor regarding the occurrence of
deviation and details of initial observations.

The concerned department personnel shall fill the details of the unplanned deviation along with cause and

investigation details as per Annexure II and forward the same to department head for review, assessment
and comments.

While review, concerned head of the department shall incorporate corrective and preventive action based

on assessment. Then the ‘Unplanned Deviation Report’ shall be forwarded to Plant Head for review.

Then ‘Unplanned Deviation Report’shall be submitted to the QA for review and approval.

QA shall assign a unique number to each unplanned deviation report as follows;

The reference number for an unplanned deviation report shall consist of ten (10) alphanumeric characters.

For example, UDR/16/001 shall be assigned to the first unplanned deviation of year 2016.

In the above unplanned deviation report number, the 1st, 2nd & 3rd characters ‘UDR’ stands for
‘Unplanned Deviation Report’.

The 4th character “/” is a forward slash.

The 5th & 6th characters ‘16’ represent the last two digits of the year 2016.

The 7th character “/” is again a forward slash.

The 8th, 9th & 10th characters ‘001’ are a sequential number.

QA shall maintain a logbook for the unplanned deviations as per Annexure III.

The filled form shall be forwarded to QA head after review by QA.

Head – QA & Head – concerned department shall assess unplanned deviation for its impact on product

quality. Details shall be documented as per Annexure II.

Head QA may recommend for performing any additional studies, if required.

If the deviation does not affect product quality, Head – QA shall allow further processing of the batch in

question.

If there is probability of product quality getting affected, Head – QA shall assess the impact on product

quality before allowing further processing of the batch.

Product may be “Quarantined” in sealed containers, if required. Containers shall be labeled, indicating
product name, Batch No., Manufacturing Date, Expiry Date & Batch size. The labeled containers shall be

kept in secured quarantine area.

Head – QA along with the Head of concerned department shall investigate & find out the root cause of
the problem that resulted in the deviation as per SOP on CAPA.

 Based on the investigation, the proposed corrective and preventive action shall be taken to avoid any

such reoccurrence and the same shall be implemented.

If required Formulation Research & Development (FR&D) shall be consulted by QA to review impact on
product quality and decide upon the future course of action(s).

Closure of Deviation

In conclusion, Head – QA shall close the deviation by reviewing and assessing the impact of deviation on

the quality of the product.

Any supporting data and comments required to close the deviation (e.g.stability data) shall be recorded or
attached to the deviation report.

The time line for closure of deviation (planned or un-planned) shall be not more than 30 working days. If
required, extension should be taken.

Both planned and unplanned approved deviations shall be controlled by QA and the same shall be
documented in the respective BMR also.

(Note: The planned deviation shall be implemented after the approval of QA).

Forms and Records (Annexures)

Planned Deviation Report – Annexure-I

Unplanned Deviation Report – Annexure-II

Logbook for Planned/Unplanned Deviation Reports – Annexure-III

Distribution

Master Copy- Quality Assurance

Controlled Copies -Engineering, Human Resource, Production, Quality Assurance, Quality Control,

Regulatory Affairs, Warehouse

History

Date Revision Number Reason for Revision

– 00 New SOP

Annexure – I

Planned Deviation Report

1.0 Review by Department Head (Comments):


Reviewed by Name Signature Date

2.0 Review by Plant Head(Comments):

Reviewed by
Name Signature Date

QA Review / Approval

Comments received from QP attached: Yes /No / NA

Any additional studies required: Yes / No

Stability Studies, Additional Quality Testing,Others

___________________________________________________________________________

QA Comments:

___________________________________________________________________________

Deviation: Approved Rejected

The Planned Deviation is limited to time / No. of Batches: _________________

Review by Head – QA Name Signature Date

Implementation of Deviation

Deviation implemented by (department) :_______________________________

Observations (If any):______________________________________________

Data Generated (If any): _________________________________________________

Quality Profile of batches affected (If applicable): _____________________________

Name Signature Date

Implemented By

Department Head 
 QA Review of Implementation & Closure

QA comments: ____________________________________________________

All recommendations fulfilled: Yes /No

If No, Justification: ______________________________________________________

Data generation completed: Yes / No

If No, Justification: ______________________________________________________

Can the Deviation/Change be made permanent through change control? Yes/ No

Remarks (If any): _______________________________________________________

Affected batch can be released? Yes/No

Closure Approved Name Signature Date

By Department Head

/ Nominee

Closure Approved
By Head-QA/

Nominee

Annexure – II

Unplanned Deviation Report

Date _______

Deviation Initiation

Unplanned
1.1 Deviation Report ________________ (to be assigned by QA)
No.:

Deviation
Reported By
1.2
(Department):

1.3 Product Name: Batch No.: _________ Market: ___________


 ___________

Batch Size:
1.4 Mfg. Date: _________ Expiry Date: _______
______________

Procedure Process Equipment Standard Batch Size

Deviation
Others( If any) specify:
1.5
related to:

Potential Quality Yield GMPs Manufacturing Process

1.6
Impact On Others ( If any) specify :

Deviation
1.7
Details:

Cause for
1.8
Déviation

Investigation
1.9
Details:

Proposed
1.10 Corrective
Action

Proposed

1.11 Preventive
Action

Initiated Name Signature Date

By

2.0 Review by Department Head (Comments):

Name Signature Date

Reviewed by

3.0 Review by Plant Head(Comments):


Reviewed by Name Signature Date
Plant Head

QA Review for implementation of CAPA (Comments):_____________

4.0
Details of any additional studies Required / Performed:

Name Signature Date

Reviewed by

QA

Review & Deviation Closure by Head – QA (Comments):

5.0

Reviewed by
Name Signature Date
Head-QA

Annexure -III

Log Book for Planned/Unplanned Deviation Reports

Initiated Approved Closed

Sr. Expected date
PDR/UDR Deviation By out on
Date for / Remarks
No. No. Related to
& Deptt. Implementation Rejected (sign/date)

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