{"id":55308,"date":"2021-03-18T17:25:16","date_gmt":"2021-03-18T21:25:16","guid":{"rendered":"https:\/\/caireadydev1.wpenginepowered.com\/life-sciences\/?p=55308"},"modified":"2025-06-21T17:53:19","modified_gmt":"2025-06-21T21:53:19","slug":"human-error-and-how-history-repeats-itself","status":"publish","type":"post","link":"https:\/\/caiready.com\/life-sciences\/blog\/human-error-and-how-history-repeats-itself\/","title":{"rendered":"Human Error and How History Repeats Itself"},"content":{"rendered":"<p><span style=\"font-weight: 400;\">In an industry where the need for accuracy and compliance is essential, there is a category of error which still occurs at an astounding rate, affecting both cost and product availability.\u00a0 In the case where the human is part of the process, there will always be a \u201chuman error\u201d factor.\u00a0 This is the largest variable in the manufacturing process.\u00a0 The interesting part is that most of the errors are preventable, especially given that the most common area where the FDA finds observations is related to procedures.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Why is it that writing and following procedures is one of the most cited issues by the FDA?\u00a0 Procedures have been required since the beginning of time, or as part of every pharmaceutical and biotech facility in my career. \u00a0 Companies struggle to write good procedures.\u00a0 The evidence is clear\u2026 this is an easy win to eliminate many regulatory findings.\u00a0 As shown below, history continues to repeat itself with regards to procedures.<\/span><\/p>\n<table style=\"width: 0%;\">\n<tbody>\n<tr>\n<td style=\"width: 11.9593%;\"><b>Year<\/b><\/td>\n<td style=\"width: 41.9847%;\"><b>Drug Observations<\/b><\/td>\n<td style=\"width: 43.5115%;\"><b>Device Observations<\/b><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 11.9593%;\"><b>2020<\/b><\/td>\n<td style=\"width: 41.9847%;\"><span style=\"font-weight: 400;\">382 of 1513<\/span><\/td>\n<td style=\"width: 43.5115%;\"><span style=\"font-weight: 400;\">987 of 1602<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 11.9593%;\"><b>2015<\/b><\/td>\n<td style=\"width: 41.9847%;\"><span style=\"font-weight: 400;\">897 of 3626<\/span><\/td>\n<td style=\"width: 43.5115%;\"><span style=\"font-weight: 400;\">2215 of 4083<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 11.9593%;\"><b>2010<\/b><\/td>\n<td style=\"width: 41.9847%;\"><span style=\"font-weight: 400;\">1043 or 3796<\/span><\/td>\n<td style=\"width: 43.5115%;\"><span style=\"font-weight: 400;\">1457 or 4132<\/span><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 11.9593%;\"><b>2006<\/b><\/td>\n<td style=\"width: 41.9847%;\"><span style=\"font-weight: 400;\">938 of 3503<\/span><\/td>\n<td style=\"width: 43.5115%;\"><span style=\"font-weight: 400;\">1376 of 4444<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><a href=\"https:\/\/www.fda.gov\/inspections-compliance-enforcement-and-criminal-investigations\/inspection-references\/inspection-observations\" target=\"_blank\" rel=\"noopener nofollow\"><span style=\"font-weight: 400;\">Inspection Observations (24 November, 2020)<\/span><\/a><\/p>\n<p><span style=\"font-weight: 400;\">In the development and implementation of procedures, there are common issues, listed below,\u00a0 which have repeated themselves throughout the history of this industry.\u00a0 Consistently for over 20 years, these are the top findings \u2013 not just top procedure findings, but top overall findings for both drugs and devices.\u00a0 They include:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Procedures not in writing, fully followed<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Lack of or inadequate procedures<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Lack of or inadequate complaint procedures<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">If we know there are repeat findings over the history of the industry, why can\u2019t we fix the problem?\u00a0 Several companies believe they write \u201cgood procedures\u201d.\u00a0 Let\u2019s look at what some call good procedures.\u00a0 Examples include:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Over 100 pages long<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Information included not relevant to the operation<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Double digit revisions in a short period of time (2-3 years)<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">No hands-on training for procedures required to operate and maintain equipment<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">These examples create an environment inviting operators and technicians to take shortcuts or create \u201cunapproved\u201d procedures leading to deviations, CAPAs, and in some cases batches of drug product which are either quarantined or must be destroyed.\u00a0 If you were an operator on the floor pushed to make deadlines, could you find the steps you need to perform in a 100 page procedure?\u00a0 It might be a little challenging.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">In today\u2019s industry there are several types of documents within the category of procedures.\u00a0 These include \u201cpolicies\u201d, \u201cstandard operating procedures (SOPs)\u201d, work instructions, and job aids.\u00a0 For the sake of this discussion, we will focus on the SOP, which has become everything except standard.\u00a0 These have been the core documents of pharmaceutical and biotechnology operations for many years, and there have been many variations in the approach for these documents, mostly because organizations fail to establish good standards for those who are asked to write them.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">So, what should an SOP consist of?\u00a0 First and foremost, it should be concise and easy to follow.\u00a0 The word \u201cstandard\u201d should indicate this will be the way we operate and maintain our equipment.\u00a0 Major parts of the document should include<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Purpose \u2013 What purpose does the SOP serve? Why are you writing this document?<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Scope \u2013 Most equipment or systems are large, cover large processes, and\/or require different major tasks such as operations and maintenance.\u00a0 Be specific in this section to address the scope of the system or process that the SOP covers.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Tasks \u2013 Be specific and start each step with an action verb.\u00a0 Be concise and write the important information first.\u00a0 Don\u2019t leave the reader a pool of information to wade through before getting to the action required.\u00a0 This is after all a \u201cstandard operating procedure\u201d.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Supporting information \u2013 Use tables and drawings only as necessary to support the tasks required in the SOP.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">One obvious mistake organizations often make when writing the SOP is not involving others \u2013 specifically, the users of the document and experts on the processes.\u00a0 Seeing the document through the eyes of the users can lead to some important information being included.\u00a0 After all, if they can\u2019t follow it, then what good is the SOP?\u00a0 They can just make up their own steps\u2026\u00a0 which, by the way, can lead to another preventable audit finding or lost batch.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">So now what don\u2019t we include?\u00a0 Anything that is not specific to the task being performed.\u00a0 The SOP is not a training document, it is a procedure.\u00a0 While it certainly is part of the training process, the SOP is not THE training document.\u00a0 Every operator needs to understand why and how things work.\u00a0 The SOP is not the place for that knowledge transfer to take place.\u00a0 The SOP should be scannable and easy to read.\u00a0 An SOP is\u00a0 \u201c\u2026a set of instructions that describes all the relevant steps and activities of a process or procedure.\u00a0 (https:\/\/www.process.st\/writing-standard-operating-procedures\/).<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Why does history repeat itself when it comes to writing procedures that lead to the same findings in audits are repeated year after year?\u00a0 It is as simple as this\u2026in my experience, SOPs don\u2019t get the attention they require.\u00a0 They are often left until the last minute and rushed to be created by an unqualified author.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">In this Blog, I have outlined some simple parts of an SOP for organizations to use.\u00a0 There is obviously much more to consider on the technical writing side of this effort,\u00a0 but following the outline and recommendations above, as well as planning adequate time to write the documents with all the right people can prevent history from repeating itself in your organization. \u00a0 These documents are in the hands of our front-line supervisors, technicians and operators every day. Therefore, SOPs need to be made effective and useful for these people to easily follow.<\/span><\/p>\n<p>Follow CAI\u2019s Human Performance articles as we highlight the practical approach to each step of our modeled path toward operational excellence:<a href=\"https:\/\/caiready.com\/life-sciences\/wp-content\/uploads\/sites\/2\/2021\/03\/OR-staircase.png\" rel=\"attachment wp-att-55618\"><br \/>\n<img fetchpriority=\"high\" decoding=\"async\" class=\" wp-image-55618 aligncenter\" src=\"https:\/\/caiready.com\/life-sciences\/wp-content\/uploads\/sites\/2\/2021\/03\/OR-staircase.png\" alt=\"\" width=\"600\" height=\"668\" \/><\/a><\/p>\n<p><span style=\"font-weight: 400;\">References:\u00a0\u00a0<\/span><\/p>\n<ol>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><a href=\"https:\/\/www.pharmaguideline.com\/2019\/11\/5-most-common-483s-in-fda-inspections.html\" target=\"_blank\" rel=\"noopener nofollow\">5 Most Common 483s in FDA Inspections<\/a><\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\"><a href=\"https:\/\/www.pharmaguideline.com\/2019\/11\/5-most-common-483s-in-fda-inspections.html\" target=\"_blank\" rel=\"noopener nofollow\">Charlana Damron \u2013 Cromwell &amp; Moring<\/a><\/span><\/li>\n<\/ol>\n<hr \/>\n<p style=\"font-size: 16px;\"><span style=\"color: #002b49;\"><strong>About the Author<\/strong><\/span><\/p>\n<p style=\"font-size: 16px;\"><a href=\"https:\/\/caiready.com\/life-sciences\/wp-content\/uploads\/sites\/2\/2018\/07\/jeff-hall.jpg\" rel=\"attachment wp-att-3677\"><img decoding=\"async\" class=\" wp-image-3677 alignleft\" src=\"https:\/\/caiready.com\/life-sciences\/wp-content\/uploads\/sites\/2\/2018\/07\/jeff-hall.jpg\" alt=\"\" width=\"113\" height=\"113\" srcset=\"https:\/\/caiready.com\/life-sciences\/wp-content\/uploads\/sites\/2\/2018\/07\/jeff-hall.jpg 240w, https:\/\/caiready.com\/life-sciences\/wp-content\/uploads\/sites\/2\/2018\/07\/jeff-hall-150x150.jpg 150w, https:\/\/caiready.com\/life-sciences\/wp-content\/uploads\/sites\/2\/2018\/07\/jeff-hall-120x120.jpg 120w\" sizes=\"(max-width: 113px) 100vw, 113px\" \/><\/a><b>Jeff Hall \u2013 Human Performance Consultant<\/b><\/p>\n<p style=\"font-size: 16px; line-height: 1.25;\"><span style=\"font-weight: 400;\">Jeff Hall is an Associate Director in Human Performance services with over 30 years of experience with implementing programs to support the start-up, operation, and maintenance of process systems and equipment. He has over 20 years of experience managing projects of up to $6M and leading groups of people ranging from one to over 25 persons. Jeff has an MBA and is an expert in Project Management. He uses the skills in these two areas to manage project costs and efficiency. He has used this approach to create focused, effective, and efficient organizations and successful project implementation. He is experienced in auditing, developing programs, and leading projects in GMP, GLP, and GCP environments.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>In an industry where the need for accuracy and compliance is essential, there is a category of error which still occurs at an astounding rate, affecting both cost and product availability.\u00a0 In the case where the human is part of the process, there will always be a \u201chuman error\u201d factor.\u00a0 This is the largest variable [&hellip;]<\/p>\n","protected":false},"author":8,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[153],"tags":[],"resource-featured-status":[],"resource-type":[819],"class_list":["post-55308","post","type-post","status-publish","format-standard","hentry","category-human-performance","resource-type-blog"],"acf":[],"featured_image_src":null,"featured_image_src_square":null,"author_info":{"display_name":"","author_link":"https:\/\/caiready.com\/life-sciences\/blog\/author\/"},"_links":{"self":[{"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/posts\/55308","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/comments?post=55308"}],"version-history":[{"count":0,"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/posts\/55308\/revisions"}],"wp:attachment":[{"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/media?parent=55308"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/categories?post=55308"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/tags?post=55308"},{"taxonomy":"resource-featured-status","embeddable":true,"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/resource-featured-status?post=55308"},{"taxonomy":"resource-type","embeddable":true,"href":"https:\/\/caiready.com\/life-sciences\/wp-json\/wp\/v2\/resource-type?post=55308"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}