MICLAB-110 Laboratory Investigation and Retest Procedure for Atypical and Out of Specification Results

1. Timelines

1.1         The Laboratory OOS investigation Form 690 must be initiated within 1 working day of generation of the original OOS result.

1.2         Section A and Section B of Form 690 should be completed within 1 working day of generation of the OOS result. The purpose Phase 1 of Form 690 is to confirm or invalidate the original OOS result as soon as possible and to allow for immediate re-testing or confirmatory testing if deemed appropriate.

1.3         A DR should also be raised within 1 working day if required after the Phase 1 Investigation has been completed. A DR is required if, after completion of Section A and Section B of Form 690 the OOS result is valid.

1.4         Form 690 should be completed with 30 working days. This will allow for further re-testing or confirmatory testing to take place, including microbial identification work if required.

2. Determination of an OOS/OOL Result

2.1         For a result to be Out-of-Specification (OOS), or Out of Limit (OOL) a specification or alert limit must be applied. If a result obtained is determined to be outside the pre-defined limit for the sample being tested, the testing Technician in conjunction with an appropriate delegate must initiate a Phase 1 Laboratory Investigation.

2.2         The Microbiology Technician is responsible for:

• Being aware of potential problems that may arise during testing and monitoring potential problems that may result in inaccurate or invalid results.
• Ensuring all test acceptance requirements are met.
• Reporting an OOS/OOL result to the Microbiology Manager.
• Investigating the out of specification result by initiating Form 690 and a Phase 1 Laboratory investigation.

2.3         Upon completion of Section A and Section B of the form, approval must be sought from Laboratory Manager.

2.4         If the OOS result is found to be valid, the Microbiology Technician should raise a Deviation Report (DR) for the OOS Investigation immediately and document the DR number on Section A of Form 690.

2.5         At this time, an initial evaluation for further testing is undertaken (Section C of OOS Report and Investigation Form) and deemed to be appropriate or otherwise.

2.6         If a determinant error is found, it is explained in Section B of Form 690 and the result will be invalidated. In this instance a re-test of the original or retention sample can be conducted is the quality of the re-test samples is deemed to be representative of the original sample and the time of sampling.

2.7         If no determinant error is found, confirmatory testing may be performed in order to confirm the out of specification result if deemed appropriate. Prior approval for confirmatory testing by Microbiology Manager is required.

NOTE: When considering whether re-testing or confirmatory testing is valid, any factors that may potentially affect the sample quality should be considered, including but not limited to the age and storage conditions of the original or retention sample and whether the sample type has inherently antimicrobial characteristics. In some cases, re-testing a retention sample may be of no value, and other criteria should be assessed in the context of product release.

2.8         Repeat testing or confirmatory/ investigation testing is initiated only when approval from Micro Manager has been granted.

2.9         Where repeat testing, re-testing or confirmatory testing is conducted, Section C of  Form 690 must be completed, including the number of replicates used for testing, the acceptance criteria for the additional test results and the justification and reason for conducting the additional testing. When re-testing refer to Section 5 for determination of the re-test protocol.

2.10       Results from other testing are recorded in Section C of Form 690.

2.11       If a batch or partial batch is rejected as a result of the out of specification investigation, a level 1 Investigation should be carried out.

2.12       Included in Phase 2, Section C of Form 690 is the batch disposition as well as the corrective and preventative actions when applicable.

2.13       The action plan is reviewed by the Laboratory Manager, or the delegates and the Technician.

3. Initiating Form 690

3.1         For each Action or Alert Limit excursions within the scope of this procedure, a Microbiology Laboratory OOS/OOL Investigation and Report Form 690 is to be initiated.

3.2         Each OOS/OOL Investigation Report form must be assigned a unique identifying number. This number should be referenced in any relevant DR or Investigation Reports associated with the OOS/OOL result.

3.3         The OOS/OOL Investigation report form should be attached to the DR reference where appropriate, and filed in the Microbiology Laboratory Investigations file.

4. Laboratory Investigation Process

4.1          General

4.1.1      In the initial instance of recording an OOS/OOL result, notify Microbiology Manager and/or appropriate delegates.

4.1.2      A test may be repeated when the Initial test has been invalidated due to an error in procedure, (including Technician or equipment failure, or test acceptance criteria not met).

4.1.3      Microbiology Laboratory Investigations will be conducted in two phases – Phase 1 and Phase 2 as detailed below. Phase 1 is the review of the testing procedures by the microbiology technician to eliminate the possibility of laboratory introduced error or contamination. Phase 2 will investigate the OOS result in more detail.

4.1.4      Under normal conditions Alert Level excursions (OOL) will only require Phase 1 and if result is deemed valid, microbial identification and simple trend reports should be conducted. No DR is required for OOL results. Specific Test procedures should provide guidance on when OOL results should be more thoroughly investigated including when to raise DR.

4.1.5      For Action Level excursions (OOS) it is necessary to investigate thoroughly to determine a definitive cause and recommend corrective and preventative actions, (CAPA). If an OOS result, is deemed valid, A DR should be raised in accordance with QMS 035 and further investigated should be conducted.

4.1.6      Phase 1 and 2 should include assessment of the following details as a guideline. This list is not exhaustive and other relevant information should also be included where possible.

4.2          Phase 1

4.2.1       When completing Phase 1 of Form 690 for OOS/OOL results the following details should be evaluated.

• Sample collection, storage and preparation
• Sample and test preparation
• Test equipment (calibration)
• Technician Training records
• Expiry of consumables
• Media quality control passed
• Test method followed
• Observations made during test procedure.
• All calculations checked and verified
• All test control results, where relevant, are satisfactory
• Review of other test results for the test session, to determine a trend

4.2.2       At the conclusion of Phase 1 Investigation, an evaluation of the validity of the original OOS/OOL result should be made. If through the investigation process, it has been demonstrated that the OOS/OOL result is valid, a DR should be raised and a more detailed investigation initiated, including a root cause analysis.

4.3          Phase 2

4.3.1      Phase 2 involves a thorough systematic analysis of the incident, to determine the root cause for the OOS result. The investigation should be tailored for each incident to reflect the significance of meeting or exceeding either the ALERT or ACTION Levels.

4.3.2      The minimum requirements for most situations are listed as below, this list is by no means exhaustive and specialist assistance from departments other than Microbiology should be utilised in the investigation.

4.3.3      Where re-testing, repeat testing or confirmatory or investigational testing is required to confirm the root cause, refer to Section 5.

5. Retest Procedures

5.1          Prior to conducting any re-testing, Microbiology Manager or delegate must be consulted.

5.2          As part of Phase 2, further testing may be required to determine a root cause(s). Further testing may also be required if a possible cause has been identified.

5.3          A second technician may perform retesting where appropriate or required.

5.4          Standard Retest Protocol

5.4.1      The retest protocol generated in Phase 2 must specify which retest results will be reported

5.4.2      Non-Sterile Bioburden Samples (RM, FCB, BSB, Water) – Perform a retest in triplicate on the original sample and on a retain sample if available.

• Where original result has been invalidated (Phase 1), re-test of original sample, using original sample size should be conducted.
• If retests of both original and retain sample confirm the original result, report the initial result.
• If retest do not confirm the initial result, document results of the retests on Form 690 (Phase 2, Section C); no further testing is permitted. Microbiology Manager or delegate will evaluate all result in order to determine which results will be reported.

5.4.3      Endotoxin Samples – Refer to test specific procedure in relation to the number of re-tests to be performed.

5.4.4      Where original result has been invalidated (Phase 1), re-test of original sample, sample should be conducted.

5.4.5      Where original result is deemed valid, additional investigational testing may be permitted.

5.4.5.1    If retest of both original and retain samples confirm the original result, report the highest value obtained (i.e. worse case)

5.4.5.2    If any of the following scenarios occurs, all results should be documented on Form 690 (Phase 2, Section C); no further testing is permitted. Microbiology Manager or delegate will evaluate all result in order to determine which results will be reported.

• Retest of original sample confirm original result but retain sample retest results are different from original result.
• Retest results of both original and retain samples are different from original results.
• Retest of retain sample confirm original result but original sample retest results are different from original result.

5.4.6      Sterility Test – Retesting (using additional samples or retain samples) is only permitted where there is unequivocal evidence which invalidates the sterility test. Refer to MICLAB 060 for further guidance.

Note: If there is not a sufficient quantity remaining from the original sample for additional testing, new samples should be selected by sampling throughout the batch using the original sample plan.

6. Appendix 1 – Flow Chart for Processing Microbiology Laboratory OOS/OOL Investigations

7. Summary of Changes

Phase 1

PART A – Product or Sample Details

PART B – Evaluation of Laboratory Testing

PART B – Evaluation of Laboratory Testing (continued)

Note : If any of the above questions were answered NO, an evaluation of the validity of the test needs to be conducted by the Micro Manager.

NOTE: Refer to MICLAB 110 for appropriate Retest Procedures.

Phase 2

PART C – Retest Protocol

PART C – Retest Protocol (continued) – Retest Results