FOR PHARMACISTS · REFERENCE EDITION 8.0261 monographs · 32 SOPs · 18 forms

SOP-015 / SOP v2.0

Deviations, CAPA, complaints and recall

Errors, near misses and problems identified after supply.

Procedure

  1. Immediately protect patients and staff: stop work, isolate materials and alert the responsible person. Urgent clinical care comes before paperwork.
  2. Record time, product, lots, facts and available evidence without deleting original data. Separate facts from assumptions.
  3. Assess scope and other batches sharing the material, equipment or process. Quarantine potentially affected items.
  4. The responsible person determines communication with prescribers, recipients and authorities under applicable obligations. Maintain recall records and quantity reconciliation.
  5. Analyse root cause and assign corrective/preventive actions, owners and deadlines. Retraining alone is insufficient when the system causes the error.
  6. Verify CAPA effectiveness and document closure. Periodically exercise a mock recall to demonstrate traceability.

Edition-specific detail

Record immediate containment, affected batches and shared materials. Separate correction of the incident from root cause, corrective and preventive action. Recall reconciles produced, supplied, recovered and unaccounted quantities in F-007/F-018. Closure requires effectiveness evidence and a dated responsible-person decision.

Stop criterion

Do not reuse affected material or restart the process before a documented decision.

Related forms

F-007, F-018

Sources and references

  1. NAPRA — Model Standards for Pharmacy Compounding of Non-sterile PreparationsMarch 2018, clarification January 2022Sections 4–9Risk, personnel, facilities and QA; its historical BUD table is not used for current USP defaults2026-09-12
  2. NAPRA — Guidance Document for Pharmacy Compounding of Non-sterile PreparationsMarch 2018, clarification January 2022Sections 5, 6 and 7; master/batch records, delivery, qualityQuality-system implementation; historical BUD table not substituted for 2022 USP revision2026-09-12
  3. PIC/S — Guide to Good Practices for the Preparation of Medicinal Products in Healthcare EstablishmentsPE 010-4, 1 March 2014Chapters 1–9; Annex 2 (nonsterile liquids, creams, ointments)Professional quality-system framework; not automatic national legal adoption or certification2026-09-12