Corrective and Preventive Actions

(CAPA)

Corrective Actions
The

process of reacting to an existing product problem, customer complaint or other nonconformity and fixing it.

Preventive Actions
A

process for detecting potential problems or nonconformances and eliminating them.

Why CAPA?

Regulatory Requirements

Both FDA and ISO require an active CAPA program as an essential element of a quality system.

Customer Satisfaction
The ability to correct existing problems or implement controls to prevent potential problems is essential for continued customer satisfaction

Good Business Practice

Quality problems can have a significant financial impact on a company.

CAPA Procedures

Implementing an effective and fully compliant Corrective / Preventive action program is a seven step process. Each step must be thoroughly documented!

Properly documented actions provide important

CAPA Procedures
Seven Steps
1.
2. 3.

4.
5. 6. 7.

Identification clearly define the problem Evaluation appraise the magnitude and impact Investigation make a plan to research the problem Analysis perform a thorough assessment Action Plan create a list of required tasks Implementation execute the action plan Follow Up verify and assess the effectiveness

1. Identification

The initial step in the process is to clearly define the problem or potential problem. This should include: the source of the information, a detailed explanation of the problem, Documentation of the available evidence that a problem exists.

1. Identification

Source of the Information

Process monitoring

Risk analysis

This information is important for the investigation and action plan, but also useful for effectiveness evaluation and communicating the resolution of the problem.

1. Identification

Explanation of the Problem

A description of the problem is written that is concise - but complete. The description must contain enough information so that the specific problem can be easily understood.

1. Identification
Evidence

List the specific information, documents, or data available that demonstrates that the problem does exist.

This information will be very important

during the investigation into the problem.

2. Evaluation

The situation must be evaluated to determine both the need for action and then, the level of action required. An evaluation should include: Potential Impact of the problem. Risk to the company or its customers Remedial Action that may be required

2. Evaluation
Potential Impact

Determine and document specifically why the problem is a concern and what the impact to the company and/or customers may be.

Concerns may include costs, function,

2. Evaluation
Risk

Based on the result of the impact evaluation, the seriousness of the problem is assessed. The level of risk that is associated with the problem will affect the actions that are taken and the priority assigned to the situation.

2. Evaluation
Remedial Action

The potential impact and risk assessment may indicate a need for some immediate action to remedy the situation until a permanent solution can be implemented. In some cases the remedial action may be adequate. If so, the CAPA can then be closed, after documenting the rationale for this decision and completing appropriate follow up.

3. Investigation

A written procedure for doing an investigation into the problem is created. This procedure should include: The objectives for the action An investigation strategy Assignment of responsibility and required resources

3. Investigation
Objective

The objective is a statement of the desired outcome(s) of the corrective or preventive action. The action will be complete when all aspects of the objective have been met and verified.

3. Investigation
Strategy

A set of specific instructions for determining the contributing and root causes of the problem is written. This procedure directs a comprehensive review of all circumstances related to the problem and must consider:
- equipment - materials

- personnel
- design - software

- procedures
- training - external factors

3. Investigation

Assign Responsibility and Resources

It is important to assign someone the responsibility for each aspect of the investigation. Any additional resources (financial, equipment, etc) should be identified and documented.

4. Analysis

The investigation procedure is used to conduct the investigation into the cause of the problem. Every possible cause is identified and appropriate data collected. The results of the data collection are documented and organized. Everything related to the problem must be identified, but the primary goal must be to find the root cause.

4. Analysis
Possible Causes / Data Collection

A list of all possible causes is created which then form the basis for collecting relevant information, test data, etc. The necessary data and other information is collected that will be used to determine the primary cause of the problem.

Analysis
Results

Data may come from a variety of sources: testing results and/or a review of records, processes, service information, design controls, operations, and any other information that may lead to a determination of the fundamental cause of the problem. The data collected is organized into a useable form. The resulting documentation should address all of the possible causes previously determined. This information is used to determine the root cause of the problem. The effectiveness of the analysis will depend on the quality and thoroughness of the information available.

4. Analysis

Root Cause Analysis

Use the data to complete a Root Cause Analysis This involves finding the actual cause of the problem rather than simply dealing with the symptoms. Finding the primary cause is essential for determining appropriate corrective and/or preventive actions.

5. Action Plan

Using the results from the analysis, the best method(s) for correcting the situation (or preventing a future occurrence) is determined. All of the tasks required to correct the problem and prevent a recurrence are identified and incorporated into an action plan. The plan includes changes that must be made and assigns responsibility for the tasks.

5. Action Plan

Actions to be Completed

List all activities and tasks that must be accomplished to correct the existing problem or eliminate a potential problem, and prevent a recurrence. It is very important identify all actions necessary to address everything that contributed to or resulted from the situation.

5. Action Plan
Changes

Needed changes to documents, processes, procedures, or other system modifications should be described. Enough detail must be included so it is clearly understood what must be done and what the outcome of the changes should be.

5. Action Plan
Training

Employee training is an essential part of any change that is made and should be made part of the action plan. To be effective, all modifications and changes made must be communicated to all persons, departments, suppliers, etc. that were or will be affected.

6. Action Implementation!
The Action Plan that has been developed is executed and all identified tasks and activities completed. The actions that were taken are summarized and all modifications to documents, processes, etc. are listed.

7. Follow up

One of the most fundamental steps in the CAPA process is completing an evaluation of the actions that were taken. This evaluation must not only verify the successful completion of the identified tasks, but also assess the appropriateness and effectiveness of the actions taken.

7. Follow up
Key Questions

Have all of the objectives been met? (Did the actions correct or prevent the problem with assurances that the same situation will not happen again?) Have all recommended changes been completed and verified? Has training and appropriate communications been implemented to assure that all relevant employees understand the situation and the changes that have been made? Has an investigation demonstrated that that the actions taken have not had any additional adverse effect on the product or service?

7. Follow up
Verification Results

Make sure that appropriate information has been recorded that provides proof that all actions have been completed successfully.

7. Follow up
Validation Results

A validation of the action is done. This must document that:

The root cause of the problem has been solved, Any resulting secondary situations have been

corrected, Proper controls have been established to prevent a future occurrence, The actions taken had no other adverse effects. Adequate monitoring of the situation is in place.

CAPA Procedures
Completion

When

the Follow Up has been finished, the CAPA is complete. It should be dated, and signed by appropriate, authorized personnel.

Examples

Error Proofing (Poka yoke) Visible or Audible Alarms Process Redesign Product Redesign Training or enhancement/ modification of existing training programmes Improvements to maintenance schedules Improvements to material handling or storage