Anticipating Tensions Between Clinical Care and Study Protocol

Protocol trumps practice. This principle seems clear enough, but complying with it is not always as straight-forward as it sounds. Years of practicing medicine has reinforced the way a physician responds to medical situations. But do these responses run counter to the investigational plan? Can a site’s commitment to standard of care affect its ability to meet enrollment targets?


There’s a lot to consider.

Coping with Scoping Your CSV/Part 11 Audit

You know you need a computer systems audit, but that’s literally the extent of what you know.
Has this ever been you?

Yes, you use computers on a daily basis, and you may even use the system that needs to be audited. But you don’t spend your day thinking about where all the system components are located, how services and software are combined, and what Part 11 requirements apply. Terms like “cloud computing” make you feel slightly queasy. You’d rather get a root canal than discuss “distributed processing.” Your expertise is in manufacturing. Or clinical research. Or non-clinical lab operations. And somehow it’s your job to make sure an effective and properly-sized system audit is conducted. Great.

Notes 2 Fix Your Notes 2 File

Q: If Notes to File can be regulatory red flags, should we quit using them?
A: No, and here's why...

Regulatory inspections are often conducted long after the conclusion of the study. When an FDA investigator asks you a question about an anomaly five years after it’s happened, will anyone recall the circumstances well enough to satisfy the regulator’s concerns? You’ll be doing yourself a huge favor if you write NTFs that answer the questions regulators might one day be asking you.

When GCP & GMP Meet

Developing safe and effective drugs requires a coordinated effort across a diverse set of disciplines. This is easier to observe at some points in the process than at others. Once a product is well into human trials, it can be easy to forget that developments on the manufacturing side of the house can affect the clinicians who are conducting the studies.

Site Selection: Don't Forget About the Study Drug

As a sponsor or CRO, you understand the importance of a thorough site selection process. A site needs to be able to meet enrollment targets and time frames, protect the rights and safety of study participants, execute the protocol, deliver quality data, and maintain GCP compliance. That’s what your site feasibility surveys and pre-study visits are designed to evaluate. And as you’re assessing a site’s abilities, the site is conducting its own feasibility process. They’re mining their patient database and assessing inclusion/exclusion criteria. They’re reviewing staff credentials and ensuring they have adequate resources to manage the number of subject visits and collect the data the protocol requires.

But when we conduct GCP audits, we find there’s one perspective that is sometimes overlooked by both sides: the needs of the study drug itself.

When is a Customer NOT a Customer?

While patients are consumers of healthcare services, they can’t be considered customers in the traditional sense. The same is true of students. Over many years of teaching, I’ve noticed this parallel between the healthcare and education professions; both require significantly more “customer participation” to achieve desired outcomes than other industries do. That’s one reason it’s difficult to measure the quality of these institutions and the skills of their practitioners. That’s also why both industries focus so intently on engaging our communities; we simply can’t be successful unless we do.

“Can You Hear Me Now?”
As the old joke goes, there are 3 types of people in this world: those who are good at math and those who aren’t. Many students believe themselves to be permanent denizens of the 2nd camp. They find mathematical concepts confusing and the terminology inscrutable, so they tend not to ask questions. They’re afraid they’re being judged, so they’re not always truthful. Tests and exams fill them with anxiety, and sometimes even panic (no doubt waking to nightmares of trains leaving stations at varying rates of speed). These are the students who need my help the most. Our success in overcoming these challenges together will depend heavily on the student/teacher connection we can establish, yet few students are actually able to choose the teacher with whom they are asked to connect. Sound like healthcare yet?

Avoiding Protocol Deviations

Year in and year out, protocol deviations are the most common FDA Site Inspection finding. Why does this keep happening?

If you’ve seen FDA’s Inspectional Observation Summaries, you know that in 2015 the most frequently cited violation in clinical research by far was “failure to conduct research in accordance with the investigational plan.”  Do you know this finding also topped the list the year before that?  And the year before that?  In fact, deviating from the protocol has been the most common observation every year for the last decade.

Why does this keep happening?