Risk Management Archives

Jan 5 2021

Contract Manufacturers Need Strong Risk Management Processes

1 Comment / ISO 14971:2019 (Risk Management) / By Robert Packard / contract manufacturers, risk analysis, Risk Management

This blog discusses why contract manufacturers need to have a strong risk management process, and your company needs to help your contract manufacturers. This article was updated on April 28, 2022, and the original publication was January 05, 2011. Please ignore the date of publication at the top of the post for articles that are more than a year old.

Can contract manufacturers exclude risk management from the scope of their quality system?

Most contract manufacturers in the medical device industry exclude design from their Quality Management Systems. Unfortunately, most of the contract manufacturers also associate risk management with only the design process. Risk Management cannot be “not applicable” in an ISO 13485 Quality Management System. The requirement of section 7.1 is: “The organization shall establish documented requirements for risk management throughout product realization. Records arising from risk management shall be maintained.” The Standard also references ISO 14971 as a source of guidance on Risk Management.

Medical Device Academy also offers a Two-Part Risk Management Training Webinar for ISO 14971:2019.

Have you experienced an audit dialogue at a contract manufacturer similar to this?

The auditor asks, “How do you manage risk throughout the production process?” Then the auditee responds, “That is the responsibility of our customers. We will prepare a risk analysis if customers pay for it, but usually, customers do the risk analysis.”

For a contract manufacturer, compliance with ISO 14971 is not my primary concern as an auditor. My primary concern is to verify that contract manufacturers analyze risks associated with the processes that they perform and do their best to minimize those risks. What I don’t understand is why more companies don’t want to have strong risk management processes. Risk management is how we prevent bad things from happening. Bad stuff like scrap, complaints, and recalls. Should we expect our suppliers to have a strong risk management process?

Duh.

Why your company needs to be involved in the risk management process?

Contract manufacturers should be doing everything they can to get better at risk management. During pre-production planning, they should be asking, “What happens if…” The contract manufacturer knows best HOW things will fail in production, while the customer knows best WHAT happens when things fail in production. To be safe and effective, both companies need to collaborate on risk analysis.

In any risk analysis, you need to estimate the severity of potential harm and the probability of occurrence of that harm. For production defects, the contract manufacturer can estimate the probability of occurrence of defects (i.e., P1 in Annex E of ISO 14971:2007), but the likelihood of occurrence of harm is less. The probability of occurrence of harm is the product of multiplying P1 and P2. The probability that occurrence will result in harm is P2, and P2 is a number that is less than 100% or 1. Your company can gather pre-market clinical data and post-market clinical data to estimate P2, but before launching your product, you can only guess at the value of P2. Your contract manufacturer, however, is not able to estimate P2 at all. It’s ok to estimate risk without P2 during the design phase because this will overestimate risks and result in more conservative decisions.

In addition to P2, your contract manufacturer is also not capable of estimating the severity of potential harm. As the designer of the medical device, you will know best how your device is used and what the likely clinical outcomes are when a device malfunctions. There may even be multiple possible clinical outcomes. The contract manufacturer knows what can go wrong during manufacturing, but you will need to define the clinical outcomes due to malfunctions.

Why do contract manufacturers avoid doing risk analysis?

The reason contract manufacturers avoid doing risk analysis is because it’s time-consuming and tedious.

Too bad, so sad.

Balancing my checkbook is time-consuming and tedious too, but I balance my checkbook to prevent an overdraft charge. Not doing a risk analysis can be much more painful. Scrapping out a part can cost tens or hundreds of dollars. Complaints can cost thousands of dollars. Recalls can cost millions of dollars.

If I owned a contract manufacturing company, I would ensure that everyone in the company is involved in risk management. We don’t want scrap, we can’t afford mistakes that lead to complaints, and a recall could put us out of business.

How Medical Device Academy Can Help?

Medical device academy can help both the contract manufacturer and the specification developer utilizing a contract manufacturer as a supplier! We offer training on 14971:2019 as well as procedures on risk management and supplier quality management.

Two-part Risk Management Training Webinar for ISO 14971:2019 – Part 1 of this webinar will be presented live on Tuesday, March 29 @ 9-10:30 am EDT. Part 2 of this webinar series will be presented live on Tuesday, April 5 at 9-10:30 am EDT. Purchase of this webinar series will grant the customer access to both live webinars. They will also receive the native slide decks and recording for the two webinars.

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Sep 6 2019

What is a pFMEA? (i.e., process Failure Mode and Effect Analysis)

2 Comments / ISO 14971:2019 (Risk Management) / By Matthew Walker / Failure mode and effects analysis, failure modes, FMEA, pFMEA, Risk Management, Risk Priority Number, RPN

This article explains what a pFMEA is (i.e. Process Failure Modes and Effects Analysis) and how to use them as part of your risk management process.

RPN Scoring Table What is a pFMEA? (i.e., process Failure Mode and Effect Analysis)

I recently had someone ask for help understanding the Process Failure Mode and Effect Analysis (pFMEA) a little better. I can’t blame them, because I was lost the first time I tried to fill out a form for one. It can be confusing and overwhelming if you have never created one before.

First things first, what is a pFMEA

FMEA= Failure Modes and Effects Analysis

A lower-case letter will come before the FMEA, and that denotes the ‘what’, of what the failure is that is being analyzed. A pFMEA will often be examining process failures where a dFMEA might evaluate design failures.

Some systems capitalize all the letters. Some capitalize none. That is not what is important as long as it is consistent throughout your system. Everyone should be able to easily understand that whatever variation of pfmea is used; it means “process failure modes and effects analysis.”

What does a pFMEA do?

A pFMEA will break down your manufacturing process into its individual steps and methodically examine them for potential risks or failures. For companies that utilize our Turn-Key Quality Management System, FRM-025 process Failure Modes, and Effects Analysis can be used as a template.

For this example, we will look at receiving inspection of injection-molded casing parts for a medical device. This receiving inspection includes a manual inspection of 10 randomly selected parts out of each delivery of 100 using an optical overlay.

Process Step

This area, as the section title suggests, is the process step. When looking at the process as a whole, the pFMEA will break it down into each and every step included in that process. This area is simply that individual step that is going to be examined.

The Process Step or item function depending on what your form uses for this scenario, is going to be part of the random sampling for manual inspection of the received parts using an optical overlay. Our example is going to be the backlighting element of the optical overlay display. The backlighting element will illuminate the inspected part against the template to verify that the part is within specific dimension criteria.

Potential Failure Modes

A failure mode is a way in which that process step might fail. Since it is failure modeS, it needs to be considered that there may be more than one way for the process step to fail. Do not be fooled that because this box on the form has been filled in that the pFMEA will be complete. A thorough examination of all of the possible failures should be investigated.

Our example in this process requires the backlighting element to illuminate a visual template over the parts. The light not illuminating properly is a potential failure mode of this process.

Potential Effects of Failure

the potential effects of the failure is a look into what the ramifications would be if that failure for that process step actually happened.

In our scenario, one of the potential effects of the lighting not functioning properly is that parts outside of the designated sizing acceptance criteria may be accepted rather than rejected as non-conforming parts.

S (Severity)

The next area is the first area that requires an estimated grading of the failure. That is ‘Severity’ which is abbreviated as S. There is a scale provided in the rating section of FRM-025 that outlines the numbering system that Medical Device Academy uses.

Below is a snippet of the rating scale used, this is included with the purchase of the SYS-010 Risk Management Procedure.

Severity (S)
Severity of the effect	Scale	Definition
Business Risk	0	No potential harm to patient or user
Superficial	2	Little potential for harm to patient or user

In this case, our example is using molded plastic pieces of the outside casing of a medical device. Pieces that are too large or too small will not fit when making the final assembly of the device. These plastic pieces do not happen to be patient contacting, and do not affect the function of the device.

The evaluation of this failure is determined to have no potential effect on patient safety or increase any potential for risk of harm, therefore the severity is assigned as a ‘business risk’ meaning that it bears no risk for the user or the patient. This makes the Severity Score 0.

Causes of Failure

This column is exactly that. What might cause this identified failure to happen? In our example might be the light bulbs in the overlay machine may slowly burn out over time with use. This burnout causes potential failure.

If the bulb is expected to only have a lifetime of 100 hours, then the more hours the bulb is used, the dimmer the light may become. A slowly dimming light decreases the sharpness of the overlay template and our parts that are supposed to have a + or – size criteria of 10% now have a fuzzy template that in reality changes the overlay to show closer to + or – 13%. Now parts that are too small or too large may be accepted.

O (Occurrence/Probability)

This grading criterion is also found in the Rating section of FRM-025. This is how often the failure is expected to occur. How often will the lighting element of our optical overlay fail to function in the appropriate manner for this cause?

Hopefully not very often. In fact, regularly scheduled maintenance and calibration of the overlay machine could prevent this from ever happening in the best-case scenario. Our evaluations determine that the probability of this happening is low. However, since we cannot be certain it will never happen the potential for this risk exists and makes the Occurrence score a 4.

Current Process Controls

What is currently being done to control this risk? Our example uses regularly scheduled maintenance and calibration to prevent bulb burnout affecting the overlay.

D (Detectability)

Our current process is based on routine maintenance and visual inspection. This means that the bulb burnout is something that is visually inspected for and visual inspections for detectability on the rating scale are graded as 8. This chart is found in the Rating Section of FRM-025.

RPN (Risk Priority Number)

This is a number that is found by multiplying the Severity, by the Probability, by the Detectability. In our example, the numbers RPN is 0X4X8=32 for an RPN of 32 which is considered LOW.

pFMEA math

Below is a short video explaining the math behind calculating the Risk Priority Number

https://www.youtube.com/watch?v=OWfyHyx-zhI&feature=youtu.be

Recommended Actions

What if anything can be done to improve this process? In our example, a recommended action may be to transfer from visual only inspections to verification of light output by the meter. This makes the Detectability of the failure measurable by meter or gage which is a detectability score of 4.

This changes the RPN now to 0X4X4=16

The pFMEA shouldn’t be a solo thing

If it can be avoided this type of analysis should be done by a multidisciplinary team. Sometimes in smaller companies, people end up having to wear more than one hat. There are many entrepreneurs that have to function as the CEO/CFO/Design Engineer/RA/QA manager.

Ideally, a team approach should be used if feasible. Have the management level staff who have ownership of the processes participating in this analysis. They should know the process more intimately than anyone else in the company and should have more insight into the possible failure modes of the processes as they have likely seen them first hand. They are also the type of employee who would know the types of recommended actions to control the risk of those failures as well.

The pFMEA should also be a living document

As new failure modes are discovered they should be added to your pFMEA. A new failure mode might be discovered through a CAPA because the process had an actual failure that was not originally analyzed. Take an instance like that as an opportunity for improvement and to update your pFMEA as part of a living breathing risk management system. Also, use this as a time to re-brainstorm potentially similar failure modes that may not have been considered previously so that they can be controlled before they happen.

If you took the time to watch the video above it is also mentioned that in some instances the very first FMEA must be based on estimates because there is no data. Managers and engineers may be forced to estimate the probability of occurrence. If that is the case the FMEA should be updated in the future to adjust the (O) score to reflect what is occurring in actuality based on real data and not the theoretical data that was used for the initial estimate.

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Jun 11 2013

Benefits of Incorporating Risk Management into Procedure Documents

1 Comment / ISO 14971:2019 (Risk Management) / By Robert Packard / documentation, ISO 13485, Procedures, Risk Management

By Guest Blogger, Brigid Glass
The author discusses the benefits of incorporating risk management into procedure documents. An example procedure for Record Control is included.

I loved it when I was first introduced to FMEA many years ago. I loved the systematic approach and particularly appreciated using a Process FMEA to explain to those involved in a production process why specific controls had been implemented. I enthusiastically taught FMEA to our engineers. At the time, our bubbly, buoyant, outcomes-focused Training Manager said to me, “You Quality people have such a negative outlook. You’re always looking for what can go wrong!” Well, yes, but it’s our role to prevent things from going wrong! I’d found a tool to help me with that.

Next was EN 1441, a risk analysis standard that never satisfied and always felt incomplete. ISO 14971 followed, covering the entire lifecycle of a product with closed feedback loops. So now, product and process design risks are well covered, but ISO 13485 section 7.1 asks us to “establish documented requirements for risk management throughout product realization.” Many of us would acknowledge that we could do better despite passing audits. And what about the rest of the quality management system? I know that when we document a procedure, we already apply risk management principles in our heads, but we usually don’t apply them systematically or write down the results.

The Idea

Recently, Rob Packard and I started work on a project requiring us to generate a complete set of documentation for a QMS compliant with U.S. and EU requirements, including ISO 13485 and ISO 14971. We each had our ideas on how best to write a procedure, but this project allowed us to get some synergy going. Rob wanted to address risk management in each procedure. “Yes!” I said, thinking that there was a chance to fill that gap. But then, it was my job to develop the template for the procedures and work out how to accomplish this.

My first results looked very complicated, so I took the KISS (Keep It Simple, Sweetheart) approach: one column for the hazards and consequences and one for the risk control measures.

What I didn’t include:

I started with more complex hazard documentation (hazard ID, impact, trigger event, etc.). Still, I felt the benefits in the context of a procedure document was not balanced by the extra complexity and work required for analysis and training. It would be a hard sell to users within an organization who were not used to the risk management approach.
I decided not to assess risks and controls quantitatively for the same reasons as in the bullet point above.
Initially, I included references to implementation, but this would be difficult to maintain as other documents changed.
I thought about verification of the implementation of risk controls, then decided to leave that verification to reviewers.

Below is an example from a procedure for Record Control in which records are completed on paper and then scanned as a PDF. My list won’t be the same as yours, but it is illustrative.

Standards and regulations are essentially a set of risk controls, so they are the first starting point when identifying hazards. The list should include direct risks to products, risks to the integrity of the QMS, and regulatory risks. For those of us who have been in this industry for a while, experience, past mistakes, questions fielded in external audits, and observations of other systems will yield further hazards and appropriate controls. Audits allow updating and refining the list and testing the control measures.

Benefits of Incorporating Risk Management into Procedure Documents

Impresses your ISO 13485 auditor!
When first writing procedure documents, starting the writing process by reviewing the external requirements and systematically writing the risk section sharpens the mind as to what must be included in the procedure. This is the same approach as in design controls, where we include risk mitigators that apply to product design in the design inputs. This is part of planning in the PDCA cycle.

Supports future decision-making, in the same way, that the risk file for a product is considered when a design is changed. The risk control section of a procedure provides the criteria against which any improvement or change can be assessed. Will it enhance the risk controls, or might it introduce a new hazard?
Serves as the basis for training on the procedure. Making visible the link between potential hazards and procedural controls much more convincing than saying, “Do this because the procedure says so,” or, “It’s in the procedure because the regs say so.”

This is part 1 in a series of blogs that leads up to our Roadmap to Iso 13485 Certification Courses

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