Corrective and preventive action record
CAPA-2026-017
| CAPA number | CAPA-2026-017 |
|---|---|
| Opened | 2026-06-12 |
| Source | Deviation, DEV-2026-041 |
| Product or process | Finished-product release testing, HPLC assay (method QC-TM-022) |
| CAPA owner | QC Laboratory Manager |
| Governing requirement | 21 CFR 211.192 (investigation, extent, written record), § 211.22(a) (quality control unit), § 211.100(b) (deviations recorded and justified) |
1.Problem statement
On 2026-06-10 the second-person review of an HPLC assay sequence found that reference standard RS-118, lot 4471, was used in 6 sequences between 2026-05-28 and 2026-06-09, after its retest date of 2026-05-27. Results for 4 lots of one finished product were reported; 2 of those lots had already been released.
2.Containment and correction
- 2.1RS-118 lot 4471 quarantined and labelled "Do not use" on 2026-06-10.
- 2.2The 2 unreleased lots placed on QA hold pending retest.
- 2.3All 6 sequences re-run with in-date lot 4502 under DEV-2026-041; every result within specification and within 0.4% of the original.
- 2.4Released lots assessed by QA against the retest results: no impact on the release decision, conclusion documented in DEV-2026-041.
3.Investigation and root cause
Retest dates for reference standards are kept in a shared spreadsheet that is reconciled monthly. The chromatography data system accepts any standard ID typed at sequence set-up and checks nothing against the spreadsheet. The analyst read the vial label, which prints the receipt date in large type and the retest date in small type with no heading.
Why chain
- Why 1Why was an expired standard used? The analyst took the receipt date on the vial label for the retest date.
- Why 2Why was the wrong date read? The in-house label prints the receipt date largest and the retest date unlabelled.
- Why 3Why did nothing stop the run? The data system accepts any standard ID; expiry is checked only in the spreadsheet.
- Why 4Why was the spreadsheet not checked? It is not open at the instrument, and its May reconciliation had not been done.
- Why 5Why is there no system check? The standards inventory was left out of the LIMS when the LIMS went live.
Root cause
Extent: other batches and drug products checked
4.Corrective actions
| No. | Action | Owner | Due | Done |
|---|---|---|---|---|
| C1 | Move the reference-standard inventory into the LIMS with a hard block on use after the retest date (change control CC-2026-033). | QC LIMS administrator | 2026-07-31 | 2026-07-28 |
| C2 | Reissue the standard label with "Retest by" in the largest type and the receipt date secondary. | QC Laboratory Supervisor | 2026-07-15 | 2026-07-14 |
5.Preventive actions
| No. | Action | Owner | Due | Done |
|---|---|---|---|---|
| P1 | Apply the same LIMS expiry block to working standards, critical reagents and HPLC columns. | QC LIMS administrator | 2026-09-30 | 2026-09-24 |
| P2 | Add "every standard in date at point of use" to the second-person review checklist for all sequences. | QA Manager | 2026-07-15 | 2026-07-10 |
Signature 01: plan approval
Signed after sections 1 to 5, before the actions start.
- Role
- Head of Quality Assurance
- Printed name
- blank
- Meaning
- Approval: investigation, root cause and action plan
- Date and time
- YYYY-MM-DD hh:mm UTC
6.Effectiveness check
Criteria, set before the check
Method and data
Check due
Outcome
Result
7.Closure
The root cause is removed: expiry is now enforced by the LIMS at the point of use and the label shows the retest date first. The effectiveness criteria were met. CC-2026-033 is closed. CAPA closed.
Closed
Signature 02: effectiveness verification
Signed after sections 6 and 7, once the result meets the criteria.
- Role
- QA Manager
- Printed name
- blank
- Meaning
- Review: effectiveness verified, CAPA closed
- Date and time
- YYYY-MM-DD hh:mm UTC
CAPA-2026-017. A printed copy is for reference; the signed record in your quality system is the original.