LABORATORY QUALITY CONTROL

Course Code RIT 2.2 Revision C

Definitions:
Quality Control: the process of detecting errors

Quality Assurance: the systems or procedures in place to avoid errors occurring

 to ensure the reliability of the test results to give the best patient care !

Unreliable Performance ?
Potential consequences include: patient misdiagnosis delays in treatment increased costs
avoidable retests cost US 200million USD per year

Even a small calibration bias can effect treatment rates:

1% +ve bias in cholesterol result
5% increase in patients exceeding the treatment cut-off

3% +ve bias
15% increase in patient treatment.

Error Classification..
Pre-analytical: errors before the sample reaches the laboratory

Analytical: errors during the analysis of the sample

Post-analytical: errors occurring after the analysis

Pre - Analytical Errors..

Improper preparation of the patient: patient fasting
glucose test

stress and anxiety

urinary protein

Pre - Analytical Errors..

Improper preparation of the patient Improper collection of the blood sample: sample haemolysis
LDH, potassium or inorganic phosphate

insufficient sample volume

unable to carry out all requested tests

collection timing
24 hour urine

Pre - Analytical Errors..

Improper preparation of the patient Improper collection of the blood sample Incorrect specimen container: serum or plasma fluoride tubes for glucose
to inhibit glycolysis

EDTA unsuitable anti-coagulant for calcium

Pre - Analytical Errors..

Improper preparation of the patient Improper collection of the blood sample Incorrect specimen container Incorrect specimen storage: sample left overnight at room temperature
falsely elevated K, Pi and red cell enzymes

delay in sample delivery

falsely lowered levels of unstable analytes

Other Factors..
The sex of the patient
male or female

The age of the patient

new born / juvenile / adult / geriatric

Dietary effects
low carbohydrate / fat high protein / fat

When the sample was taken

early morning urine collection pregnancy testing

Patient posture
urinary protein in bed-ridden patients

Other Factors..
Effects of exercise
creatine kinase / CRP

Medical history
heart disease / diabetes / existing medication

Pregnancy
hormonal effects

Effects of drugs and alcohol

liver enzymes / dehydration

Analytical Errors..
The sample:
labelling
barcoding / aliquoting

preparation
centrifugation / aspiration

storage temperature
short term refrigeration medium term freezing at 20oC long term freezing at -80oC

correct test selection

Laboratory Information Management System (LIMS)

Analytical Errors..
The sample: Glassware / pipettes / balances:
used incorrectly contaminated poorly calibrated reuse of pipette tips

Analytical Errors..
The sample: Glassware / pipettes / balances: Reagents / calibrators / controls:
poor quality inappropriate storage
correct temperature badly maintained fridges or freezers

stability
shelf-life / working reagent

incorrect preparation

Analytical Errors..
The sample: Glassware / pipettes / balances: Reagents / calibrators / controls: The application:
incorrect analytical procedures poorly optimised instrument settings

Analytical Errors..
The sample: Glassware / pipettes / balances: Reagents / calibrators / controls: The application: The instrument:
operational limitations
temperature control/read times/mixing/carry-over

lack of maintenance
worn tubing / optics / cuvettes / probes

Other Factors..
Calculation errors:
incorrect factor / wrong calibration values

Transcription errors: Dilutions errors:

incorrect dilution or dilution factor used

Lack of training: The human factor:

tiredness / carelessness / stress

Post - Analytical Errors..

The prompt and correct delivery of the correct report on the correct patient to the correct Doctor. How the Clinician interprets the data to the full benefit of the patient.

Accuracy ?

How correct your result is.

Precision ?
The reproducibility of your results.

Accurate and Precise..

Imprecise but Accurate !

Precise but Inaccurate !

Specificity ?
The ability of a method to measure solely the component of interest. A lack of specificity will affect accuracy
falsely elevated values
hormones and drugs

falsely low values

BCP method with bovine albumin

Sensitivity ?
The ability to detect small quantities of a measured component.
will affect both precision and accuracy at the bottom end of the assay range.

Normal Distribution..
Mean value (x)

Frequency

Measured value

Values fall randomly about a mean value.

Precision ?
How disperse the values are. Quantified by measuring the Standard Deviation (SD) of the set of results.

Standard Deviation (SD)..

(xi - x) SD = ( ) n-1
2
The lower the SD the better the Precision.

Example:
Mean result (x) = 100 mmol/L Standard deviation (SD) = 1.0 mmol/L

Number of results (n) = 100

Mean +/- 1SD..

-1SD

+1SD

Frequency

68%

99 100 101

Values fall randomly about a mean value.

Mean +/- 2SD..

-2SD

+2SD

Frequency

95%

98

100

102

Values fall randomly about a mean value.

Which is more Precise ?

Potassium SD = 0.1 mmol/L Sodium SD = 2.0 mmol/L

Coefficient of Variation..

SD CV = x 100% Mean (x)

A %CV takes into consideration the magnitude of the overall result.

Example:
Potassium %CV = (0.1 / 5.0) x 100% = 2.0%
Sodium %CV = (2.0 / 140) x 100% = 1.4%

Sodium has the better CV and in this example is performing better than potassium.

Interpretation..
10 40 41 50 51 70 71 100 101 120 unacceptable performance need for improvement acceptable good excellent

TS Calculations
V = (Result - Mean for Comparison) x 100 Mean for Comparison
The mean for comparison could be either: the all method mean your method mean your instrument mean

TS Calculations
TS = Log10 (3.16 x TCV) V
TCV is Target Coefficient of Variation

x 100

TS Calculations
TS = Log10 (3.16 x TCV) V
3.16 is selected as a constant because:
the log10 of 3.16 is 0.5 so if V = TCV, then the target score will be 50

x 100

TS =

log10 3.16 x TCV x 100 V log10 3.16 x 3.7 3.7 log10 (3.16) x 100 50 x 100

How can Analytical Quality be Controlled ?

 Internal Quality Control (IQC).

daily monitoring of quality control sera

External Quality Assessment (EQA).

comparing of performance to other laboratories.

Internal Quality Control..

Daily monitoring
precision accuracy

Quality control sera

results within control limits indicates that analytical system is running satisfactorily

What is Acceptable ?
A sodium control has a target value of 140 mmol/L
139 mmol/L 120 mmol/L 160 mmol/L

140 mmol/L
141 mmol/L

180 mmol/L

What is Acceptable ?
A range of acceptable values is established Sodium Control:- 137 143mmol/L.

What are the Options ?

Unassayed serum:
the cheaper option !
but the laboratory must establish its own ranges

cannot be used to assess accuracy !

no externally assigned target values

Assayed serum:
with predetermined targets and ranges
established by the manufacturer.

Unassayed Serum..
Analysed extensively by the laboratory.
a minimum of 20 sets of data generated a mean +/- 2SD range established
95% of results acceptable

some laboratories may adopt tighter ranges

Assayed Serum..
Targets and ranges generated by the manufacturer: abc utilises RIQAS
database of 5,000 laboratories method / instrument / temperature specific values

Levey Jennings Chart

+2SD
+1SD
X X

143

141.5
X
X X X X X X X X

Mean

X X

X X

140

-1SD
-2SD

138.5
137

Levey Jennings Chart

+2SD
+1SD Mean
X X X X X X X X

143

141.5
X X
X X

X
X X

140

-1SD
-2SD

138.5
137

Levey Jennings Chart

+2SD
+1SD
X X

143

X X X X

X X

141.5 140

Mean

X X

X X X X X

-1SD
-2SD

138.5
137

Levey Jennings Chart

+2SD
+1SD
X X X X X X X X X X X

143

141.5 140

X
X

Mean

-1SD
-2SD

138.5
137

Levey Jennings Chart

+2SD
X X X

143
X X

+1SD
X

141.5
X

Mean

X X X X

140

-1SD
-2SD

X
X X X X X

138.5
137

Levey Jennings Chart

+2SD
+1SD
X X

143
X X

141.5
X
X X X X

Mean

X X

140

-1SD
X X

138.5
137

-2SD

Levey Jennings Chart

+2SD
+1SD
X

143

X X

141.5
X

X
X X X

Mean
X X X X X

140

-1SD
-2SD

138.5
137

Westgard Rules..
Decision criteria is dependent on the precision of the method or analyser
the less precise the method the more difficult the decision.

Westgard provides multiple QC rules: defines acceptability

minimises false rejections maintains high error detection

Westgard Flowchart..
Control data 1 point outside 2 SD Yes 1 point outside 3 SD No

In control report data

No

No

2 consecutive values outside the same 2 SD

No

Difference between 2 controls within a run exceeds 4 SD No

4 consecutive control values on one side of the mean and further than 1 SD from the mean No

10 consecutive values on one side of the mean

Yes

Yes Yes Yes Yes

Out of control reject analytical run

External Quality Assessment..

.. the main objective of EQA is not to bring about day to day consistency but to establish inter-laboratory comparability

EQA Options..
International / National / Regional
International schemes provide: a larger database of results a wider range of analytical methods a global representation of diagnostic manufacturers Compulsory or Voluntary

A Typical EQA Scheme..

Participants receive unknown samples. these are analysed blind the results returned to scheme organiser they are statistically analysed to generate a comparative report report sent to participant

RIQAS

abc

International Quality Assessment Scheme

launched in 1988 5000 participants

Management tool
to assess, review and improve performance

RIQAS..
Annual subscription
two six monthly cycles

Weekly samples
one vial reconstituted per week
tested blind as if a patient sample

Results reported back to abc

statistically analysed

Weekly Report generated