Standard Operating Procedure for Receiving and Handling of Controlled Substances in Raw Material Stores
Department | Warehouse / Quality Assurance / Security |
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SOP No. | SOP/RM/014/2025 |
Supersedes | SOP/RM/014/2022 |
Page No. | Page 1 of 15 |
Issue Date | 01/02/2025 |
Effective Date | 05/02/2025 |
Review Date | 01/02/2026 |
1. Purpose
This Standard Operating Procedure (SOP) outlines a comprehensive method for the receipt and handling of controlled substances within the raw material stores. Controlled substances require stringent security measures, documentation, and regulatory compliance to prevent misuse, theft, or unauthorized access. By adhering to this SOP, the organization ensures compliance with national and international regulations governing controlled substances, upholds Good Manufacturing Practice (GMP) requirements, and maintains accurate records for audit readiness. Additionally, this SOP provides guidelines for safeguarding materials from contamination or mix-ups and implementing secure storage conditions that maintain product integrity.
2. Scope
This SOP applies to all controlled substances delivered to the facility’s receiving dock or designated receiving area for raw materials. It includes:
- Verification of the specific license or permit required for handling controlled substances.
- Safe unloading and transfer of materials to a secure storage area, often referred to as the controlled substance vault or cage.
- Documentation requirements, including logging receipts and updating inventory management systems.
- Roles and responsibilities among Warehouse Personnel, Quality Assurance (QA), Security, and other relevant departments (e.g., EHS, Regulatory Affairs).
All personnel involved in the receipt, inspection, and storage of controlled substances—especially those requiring security clearance or specialized training—must follow these procedures. Procurement, QA, and Security must ensure that controlled substances are received, handled, and documented according to this SOP and all applicable regulations (e.g., DEA, local drug enforcement agencies).
3. Responsibilities
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Warehouse Personnel:
- Verify shipment details (labels, packing lists) and visually inspect controlled substances upon arrival.
- Maintain custody of the materials while unloading and transferring them to secure areas.
- Record details in the Raw Material Receiving Register, referencing any specific controlled substance log or vault record system.
- Report any discrepancies, damage, or labeling issues immediately to QA and Security.
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Quality Assurance (QA) Team:
- Define and oversee adherence to GMP and regulatory guidelines for controlled substances.
- Review documentation and approve or reject shipments based on integrity, labeling, or licensing issues.
- Initiate any investigations or deviations for non-compliant shipments (e.g., missing permits, incorrect labels).
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Security Department (or Equivalent Security Personnel):
- Monitor and control access to the secured storage vault or cage where controlled substances are kept.
- Maintain a log of personnel authorized to handle or escort controlled substances.
- Collaborate with Warehouse and QA to address suspected theft, tampering, or security breaches.
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Procurement Department (If Applicable):
- Ensure all Purchase Orders (POs) for controlled substances meet regulatory licensing requirements.
- Coordinate with suppliers to confirm proper labeling, documentation (including any regulatory certificates), and secure transportation methods.
- Resolve any PO- or supplier-related discrepancies if the shipment does not match the expected quantity or product description.
4. Accountability
The Warehouse Manager is accountable for the safe receipt and immediate handling of controlled substances. The QA Manager is responsible for ensuring compliance with GMP and regulatory mandates, while the Security Department oversees physical security measures. Final authority regarding acceptance or rejection of a shipment resides with QA. Any revisions to this SOP must be reviewed and approved by QA Management and, if required, the Security Department or relevant legal/regulatory affairs to remain consistent with updated regulations.
5. Procedure
5.1 Pre-Receipt Preparations
Before a controlled substance shipment arrives, Warehouse Personnel, QA, and Security must coordinate to ensure readiness. This includes reviewing permits, checking storage availability, and confirming that only authorized staff will manage the receipt.
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Documentation and Licensing Verification
- Procurement or the Regulatory Affairs department should provide any required import/export licenses, DEA Forms (if applicable), or other certifications prior to shipment arrival. Check validity and expiry dates of these licenses.
- Ensure that the Purchase Order (PO) references the correct license number and that the supplier is approved to ship controlled substances to the facility.
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Secure Area Preparation
- Confirm the controlled substance vault or cage is ready to receive new stock. Verify that environmental conditions (temperature, humidity) meet any requirements outlined in the substance’s Safety Data Sheet (SDS) or product specifications.
- Check that security systems (cameras, alarms) and access logs are fully functional and up to date.
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Personnel Authorization
- Compile a list of staff authorized to receive, handle, or escort the shipment. Typically, this includes Warehouse Personnel, a QA representative, and a Security representative.
- Provide all authorized personnel with any special personal protective equipment (PPE) or ID badges required for the handling of controlled substances.
5.2 Receiving the Shipment
Upon arrival of the transport vehicle, specific protocols must be followed to maintain security and document the handover of controlled substances.
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Delivery Vehicle Inspection
- Warehouse Personnel, accompanied by Security if necessary, inspect the exterior of the truck or van for signs of tampering or seal breaches. Compare the seal number with the shipping documentation if provided.
- If any sign of tampering is noted, escalate to QA and Security. Do not proceed with unloading until an investigation or verification is completed.
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Matching Shipment Documents
- Verify that the Bill of Lading, packing list, and any other transport paperwork match the PO details: substance name, quantity, and batch or lot numbers. Ensure the controlled substance classification is noted on the documents.
- Check for additional documentation required by local or federal law, such as a DEA Form 222 (in the US) or equivalent. If missing, contact Regulatory Affairs or QA for guidance.
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Initial Quantity Check
- Count the number of containers (boxes, drums, sealed bags, etc.) listed on the packing list. If the actual count differs, note the discrepancy in the Raw Material Receiving Register (Annexure-1) and alert Procurement and QA immediately.
- Keep the containers sealed or intact for further inspection within a secure environment. Do not open them at the loading dock unless explicitly instructed by QA or necessary for immediate verification.
5.3 Transfer to Secure Storage
Controlled substances must be promptly transferred to the designated secure area under supervision to prevent unauthorized access or diversion.
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Escort Procedure
- An authorized Warehouse Personnel member and a Security representative escort the shipment from the receiving dock to the controlled substance vault or cage. Only authorized personnel may handle or accompany the materials.
- Maintain continuous observation of the shipment. Avoid leaving the controlled substances unattended at any time during transport within the facility.
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Entry Log and Inventory Update
- Upon arrival at the secure storage area, sign in the shipment using the Controlled Substance Inventory Log (a dedicated logbook or electronic system). This log should capture the date, time, substance name, quantity, batch/lot number, and the signatures of the personnel transferring the materials.
- Update the electronic or manual Warehouse Management System (WMS) to reflect the new stock. Link the record to the PO number and any specific license data, ensuring full traceability.
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Vault/Cage Placement
- Store the containers in the predetermined location within the vault or cage, following any environmental requirements (e.g., temperature-controlled cabinets) and organizational guidelines on segregation (e.g., separate shelves for different schedules of controlled substances).
- Securely lock the area once the materials are placed. If the vault or cage uses biometric access, ensure the door logs the entry and exit times. Keep the keys or access cards restricted to authorized personnel only.
5.4 Inspection and Documentation
After the materials are safely in the secure area, QA and Warehouse Personnel must verify label details, batch numbers, and overall compliance. This step ensures that the shipment is correctly identified and legally documented.
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Label and Certificate of Analysis (CoA) Check
- With QA oversight, confirm that the label on each container matches the Purchase Order details, including substance name, batch/lot number, and quantity. Check for expiration or retest dates if applicable.
- Review any provided CoA or regulatory certificates. If the documentation indicates the substance is from a licensed source, ensure the batch number aligns with the label. Any mismatch or missing data should prompt a quarantine status until resolved.
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Security and QA Validation
- Both QA and Security representatives may initial or sign off in the Controlled Substance Inventory Log or the Raw Material Receiving Register (Annexure-1) to confirm that all items are accounted for and properly labeled.
- If the physical check reveals damage, tampering, or labeling errors, place the affected containers in a designated “Hold” area within the secure storage room. Notify Procurement for potential supplier issues and initiate a deviation if needed.
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Completed Records
- Attach or file all relevant paperwork (packing list, CoA, license copies) in the controlled substance documentation file. For electronic systems, upload scanned versions and link them to the inventory record.
- Ensure that a final entry is made in the Raw Material Receiving Register, referencing the controlled substance log or vault records. This cross-reference enables easy audits and ensures consistent traceability.
5.5 Handling Discrepancies and Deviations
Even minor discrepancies in quantity, labeling, or licensing can trigger regulatory scrutiny. Any issues must be addressed swiftly and thoroughly.
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Quantity Shortages or Overages
- If the quantity of the controlled substance does not match the PO or the transport documents, record the actual amount in the inventory log and label it as a discrepancy. Contact Procurement and QA to investigate further.
- Shortages may require immediate reporting to relevant regulatory agencies if mandated by law. Overages, similarly, must be clarified—either the supplier shipped extra by mistake, or there may be an error or potential diversion risk that requires full documentation.
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Label or Document Inconsistencies
- If the label does not match the CoA or licensing data, quarantine the shipment. QA must either confirm the correct details via supplier communication or decide on rejection if authenticity cannot be established.
- Security should monitor the quarantined materials closely until the discrepancy is resolved, maintaining chain-of-custody logs.
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Deviation and CAPA Process
- Major discrepancies or repeated issues require a formal deviation report. QA leads an investigation into how the discrepancy occurred, the potential impact on product integrity, and whether a CAPA is necessary to prevent recurrence.
- Procurement or Regulatory Affairs may engage the supplier to update packaging procedures, improve labeling, or revise shipping methods. The supplier’s performance might be re-evaluated for continued approval as a controlled substance source.
5.6 Final Release or Rejection
Depending on the inspection outcomes, QA releases the controlled substance for further use or rejects it. Secure handling remains paramount in both scenarios.
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QA Authorization
- After verifying all documentation, quantity, and physical condition, QA signs off to release the shipment for approved usage (e.g., manufacturing, lab usage). The Warehouse Manager updates the final inventory status in the controlled substance log or WMS.
- If QA identifies significant issues that cannot be resolved or that breach regulatory guidelines, they may reject the shipment. Rejected items remain in the secure vault or cage but are clearly labeled as “Rejected,” segregated from approved stock.
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Return or Disposal
- In the case of rejection, Procurement and QA collaborate with the supplier on return-to-vendor arrangements or disposal according to legal requirements. Security oversees the disposal process to ensure no diversion occurs.
- Maintain a disposal record or certificate if local regulations mandate it. Attach all relevant documentation to the batch file for audit readiness.
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Archiving and Storage
- Keep all physical and electronic records (receiving logs, controlled substance inventory logs, CoAs, deviation reports) accessible for the retention period stipulated by regulatory agencies. Only authorized personnel should have access to these records.
- Ensure data integrity practices (e.g., date/time stamps, version control, secure backups) if an electronic system is employed. Regularly audit the log to confirm that no unauthorized edits have been made.
6. Abbreviations
- SOP: Standard Operating Procedure
- GMP: Good Manufacturing Practice
- QA: Quality Assurance
- QC: Quality Control
- PO: Purchase Order
- SDS: Safety Data Sheet
- WMS: Warehouse Management System
- CAPA: Corrective and Preventive Action
- DEA: Drug Enforcement Administration (US)
7. Documents
- Raw Material Receiving Register (Annexure-1)
- Controlled Substance Inventory Log (Vault/Cage Logbook)
- Sampling Log (Annexure-2) (If sampling is needed)
- Delivery Documents (Bill of Lading, Licenses, Permits, etc.)
- Certificates of Analysis (CoAs) and SDS
- Deviation/Non-Conformance Reports (if applicable)
8. References
- 21 CFR Part 1300 – 1321 (DEA Regulations) or Equivalent Local Controlled Substance Regulations
- EU GMP Guidelines Part I – Basic Requirements for Medicinal Products
- ICH Q7 – Good Manufacturing Practice Guide for Active Pharmaceutical Ingredients
- Company-Specific Security and EHS Policies
- Approved Vendor List for Controlled Substances
9. SOP Version
Version: 2.0
10. Approval Section
Prepared By | Checked By | Approved By | |
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Signature | |||
Date | |||
Name | |||
Designation | |||
Department |
11. Annexures
Annexure-1: Raw Material Receiving Register
Date | Supplier Name | Material Name | Batch Number | PO Number | Quantity Received | Remarks |
---|---|---|---|---|---|---|
01/02/2025 | Controlled Supply Co. | API-CS1 | CS-Batch-001 | PO-12345 | 50 kg | No Discrepancy |
02/02/2025 | Secure Pharm Ltd. | API-CS2 | CS-Batch-002 | PO-67890 | 20 kg | Seal Tampered |
Annexure-2: Sampling Log
Date | Material Name | Batch Number | Sampling Personnel | QC Test Performed | Result |
---|---|---|---|---|---|
01/02/2025 | API-CS1 | CS-Batch-001 | John Doe | Identity, Potency | Pass |
03/02/2025 | API-CS2 | CS-Batch-002 | Jane Smith | Identification | Pending |
Revision History:
Revision Date | Revision No. | Revision Details | Reason for Revision | Approved By | Page No. | Ref. Point No. | Details of Revision |
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01/01/2024 | 1.0 | Initial Version | New SOP Creation | QA Head | All | All | Established SOP for controlled substance receiving |
01/02/2025 | 2.0 | Updated Security Procedures | Standardization of Document | QA Head | All | All | Expanded guidelines for licensing checks and vault documentation |