Quality Assurance in

Hematology Laboratory

Suhair.A.A./ Quality Assurance / 3rd

year 1
Quality Assurance includes
• Pre Analytical Control
• Post Analytical Control
• Analytical Control
➢Internal Quality Control
➢External Quality Assessment

Suhair.A.A./ Quality Assurance / 3rd

2 year
◼ Quality assurance is essential in
hematology to ensure that laboratory tests
are carried out reliably.
◼ Quality assurance is concerned with all
steps of laboratory practice.
◼ The process from specimen collection
included in the pre-analytical portion to
transmission of the report to the clinician
which include the post analytical control.
And the analytical process in-between.
Suhair.A.A./ Quality Assurance / 3rd
year 3
 PRE-ANALYTICAL CONTROL

Suhair.A.A./ Quality Assurance / 3rd

4 year
Understanding functionality of
the instrument:
• principles of operation
• startup or daily checks
• shutdown procedure
• normal sights and sounds of the instrument
• familiarize staff to troubleshooting manual

Suhair.A.A./ Quality Assurance / 3rd

5 year
◼ Non-technical people will say that the
instruments can run themselves now you don’t
need to know anything just put the blood on
the instrument and push a button and then you
get the results.
◼ This is so untrue. It is very important for all
staff to understand what happens to that blood
is sampled by the instruments.

◼ When they get the results which is involved in

the Post analytical they need to decide if the
results are correct.

Suhair.A.A./ Quality Assurance / 3rd

year 6
◼ If there are problems then we need to be able to
troubleshoot where the inaccurate result came
from. Is it from the sampling valve? Are the
pressures and vacuums correct to move the
sample about the tubing. Is there a problem with
the reagents? All of these questions can be
answered if the staff to have a good
understanding of the working of the instrument.
◼ Performing startup and daily checks is another
important area. The results can also tell you if
your instrument is functioning correctly.

Suhair.A.A./ Quality Assurance / 3rd

year 7
◼ Then at the end of work day the shutdown. As we all
know blood is very sticky mainly caused by the protein.
This protein will coat all the tubing and parts of the
instrument so that shutdown is important because the
reagent will clean those surfaces.

◼ Next knowing what are the normal sounds and sights of

the instrument. When we walk up to it we should be
looking to make sure we don’t see any leakage. Same
with any unusual sounds.

◼ Part of staff training with a new instrument is familiarizing

them to the troubleshooting manual.

Suhair.A.A./ Quality Assurance / 3rd

year 8
Hematology Subsystems
◼ On most hematology instruments they are
broken into three subsystems
➢ Electronic
➢ Fluidic
▪ Pneumatics (pressure and vacuums)
▪ Hydraulics (liquids)
➢ Reagent

Suhair.A.A./ Quality Assurance / 3rd

9 year
Proper Specimen Collection
◼ Analyze only specimens that were
properly collected and stored.
➢ Correct Tube
➢ Correct amount of specimen in tube
➢ Proper mixing
➢ Cleanliness of puncture area
➢ Storage

Suhair.A.A./ Quality Assurance / 3rd

10 year
Exercise 1

Suhair.A.A./ Quality Assurance / 3rd

year 11
 Pre-Analytical Example 1
21-May-2015
13:45

WBC 0.05 x 10^3/L PASS

RBC 0.00 x 10^6/L PASS

Hgb 0.00 x g/dl PASS

Plt 10.0 x 10^3/U FAILED

Suhair.A.A./ Quality Assurance / 3rd

12 year
Example 1 - Here we have a
background printout after start-up. As
you can see the Platelet background
failed. First would look at your
troubleshooting guide.
What would you think most likely first
step would be?
* Perform another background count.

Suhair.A.A./ Quality Assurance / 3rd

year 13
Repeat Background

Here is our rerun and still platelets are out even more. Once
again would check your troubleshooting SOP.

21-May-2015
14:00

WBC 0.05 x 10^3/L PASS

RBC 0.00 x 10^6/L PASS

Hgb 0.00 x g/dl PASS

Plt 15.0 x 10^3/U FAILED

Suhair.A.A./ Quality Assurance / 3rd

14 year
Corrective Action:
◼ some possible corrective actions tobe
perform :
◼ Check when reagent(s) last changed.
◼ Change the most recently added reagent.
◼ If none recently added change the diluent.
◼ Rerun start-up

Suhair.A.A./ Quality Assurance / 3rd

15 year
Repeat Background
21-May-2015
14:30
WBC 0.05 x 10^3/L PASS

RBC 0.00 x 10^6/L PASS

Hgb 0.00 x g/dl PASS

Plt 2.0 x 10^3/U PASS

Suhair.A.A./ Quality Assurance / 3rd

16 year
So for the example background is in and we
can continue with our daily maintenance.
But just like any problem we need to
document the corrective action and try to
figure out possible causes of it.

Suhair.A.A./ Quality Assurance / 3rd

year 17
Causes for high background

◼ The uptake tubing got contaminated.

◼ Reagent agitated before connecting
to instrument.
◼ Dried reagent spills or leaks.

Suhair.A.A./ Quality Assurance / 3rd

18 year
◼ Here we have a typical counting chamber. The
diluted sample enters the chamber and is draw
through the aperture to the other side. If everyone
remembers the coulter principle there is an
external and internal electrode. When sample is
pulled through the aperture there is a change in
electrical current. This change in electrical current
is sized and counted either as a RBC, Platelet or
WBC depending on the aperture. So if there is
salt deposits near the aperture this can create
extra electrical impulses. Always clean all spills
and leaks immediately.

Suhair.A.A./ Quality Assurance / 3rd

year 19
 Suhair.A.A./ Quality Assurance / 3rd
20 year
Pre-Analytical Example 2
All parameters have a “P” code
Partial Aspiration

Suhair.A.A./ Quality Assurance / 3rd

year 21
What can give this code?
◼ Sample could be clotted.
◼ Hemoglobin is less than 4 g/dl
◼ Sample volume too low.
◼ The blood detector was turned off.
◼ Check your instrument manual.

Suhair.A.A./ Quality Assurance / 3rd

22 year
• As for any problem the first step is to consult the
troubleshooting guide. Here are some reasons may have
gotten this code/error message.
• Check the sample for clots.
• Even though this seems impossible we have seen patients with
low hemoglobin but usually not the norm. To confirm if it is due
to a low hemoglobin can run through open/manual mode. This
bypasses the blood detector. If there were no clots and the
result repeats manually then we technically can take the result.
One last thing should do is make sure that the blood was not
drawn through or above an IV line and was diluted out by
saline. Check the volume in the tube. If less than 1 ml can’t be
aspirated in auto/closed mode. Could be run in manual mode
but should not. This sample would be diluted out and cause
false low results.

Suhair.A.A./ Quality Assurance / 3rd

year 23
Other Corrective Steps
Here are some other possible steps you
may find in your troubleshooting section:
◼ Troubleshoot for leaks, kinks or plugs
along the sample flow path.
◼ Ensure the aspiration lines are clean.
◼ Check for needle plugs.
◼ Call Service Hot Line

Suhair.A.A./ Quality Assurance / 3rd

24 year
Post-Analytical Control

Understanding your
instrument results:

Suhair.A.A./ Quality Assurance / 3rd

year 25
◼ Next we will look at post-analytical control.
Post analytical looks at the results and
determining if they are correct. Usually
instruments have different flags, codes
and messages. We will look at some of
these.

Suhair.A.A./ Quality Assurance / 3rd

year 26
Flags
• Can be a letter or symbol that appears to
right of the result.
➢ Manufacturer controlled
➢ Aspiration, Linearity, interference
➢ Laboratory controlled
➢ Critical range
➢ Decision rules

Suhair.A.A./ Quality Assurance / 3rd

27 year
◼ Here we have examples. The one on the
left shows the instrument flag. These are
from Coulter instrument. The other
instruments have similar flags. Please
check you manual for them.
◼ The middle one set by the lab showing the
monocytes are above our upper normal
range.
◼ The far right shows a combination of
instrument and laboratory flags.

Suhair.A.A./ Quality Assurance / 3rd

year 28
 Suhair.A.A./ Quality Assurance / 3rd
29 year
Codes
◼ Symbols that appear in place of results
➢ Indicatebeyond reportable range +++++
➢ Vote-out of aperture
➢ Unable to calculate result
➢ Clogged flow cell

Suhair.A.A./ Quality Assurance / 3rd

30 year
Messages
◼ Usually manufacturer messages
◼ Indicate possible abnormal cells,
clumping, agglutination
◼ Used to decide on reporting of instrument
vs manual differential or verification of
measured results.
◼ Here are some Messages that you can
see:
Suhair.A.A./ Quality Assurance / 3rd
31 year
 I
W

Suhair.A.A./ Quality Assurance / 3rd

32 year
Patient Results
• Are the results consistent with the patient’s
condition?
• Delta checks
➢ Can be set on instrument or LIS.
➢ Checks against previous result.

➢ Value set by laboratory.

Suhair.A.A./ Quality Assurance / 3rd

33 year
H & H Check/Difference

◼ Hgb x 3 = HCT +/- 3%

◼ If > +/-3 can indicate a problem.
➢Instrument
➢Sample

Suhair.A.A./ Quality Assurance / 3rd

34 year
Exercise 2

Suhair.A.A./ Quality Assurance / 3rd

year 35
◼ A 45 year old women had her blood drawn for
routine testing. A CBC was run on a Coulter
GENS instrument?
◼ What stands out on these results?
◼ Low platelets, all the flags
◼ What should be done? Make a slide and
confirm results.

Suhair.A.A./ Quality Assurance / 3rd

year 36
 Post Analytical Example 1
 Laboratory Results
 WBC - 8,900/uL
 RBC - 4,460,000/uL
 Hgb -13.4 g/dl
 HCT- 40.7%
 Platelets - 56,000/ul
 MCV - 91.1.1fl
 MCH - 29.9pg
 MCHC - 32.8g/dl
 RDW - 23.1%
Suhair.A.A./ Quality Assurance / 3rd
37
 Instrument Differential
 Neutrophil % - 52.5%
 Lymphocyte % - 35.2%
 Monocyte % - 10.4%
 Eosinophil % - 1.4%
 Basophil % - 0.5%
 Flags
 WBC interference (*)
 Micro/Fragmented RBC
 Giant Platelets
 R (Review)-code on
Platelets
 Platelet Clumps
year
◼ So here is what the tech sees
when they look at the smear.
◼ What is it?
◼ Answer: Platelet
Satalitosis/Platelet clumps
◼ Couple reporting choices.
◼ First could try vortexing the
purple top for about 1-2
minutes, make a slide then run
manually on the instrument.
This sometimes gets rid of the
clumps.
• If none of these get rid of the
• Second possibility is drawing a
blue top. Sometimes the EDTA
in the lavender can cause the
clumping. You run it on your
instrument and make a slide. If
you see no clumping then the
WBC and platelet count from the
blue top can be used. But what
has to happen to the results
before reporting them? They
need to be multiplied by 1.1 due
to the dilution of the
anticoagulant in the blue top.
clumping then should report out
an estimate only no numerical
result.

Suhair.A.A./ Quality Assurance / 3rd

year 38
 Suhair.A.A./ Quality Assurance / 3rd
39 year
Here is what it looked like after vortexing. If you choose to use this
procedure you will have to validate it. This can be done by running at
least 20 samples that do not have any platelet clumping seen on the
smears. After the initial run then you would vortex each sample for
specific amount of time. We did 2 minutes. You would make a slide
immediately and run it manually not closed mode through the
instrument. You do it for all 20 samples than calculated the %
difference before and after vortexing. You would want to see less than
10% difference in the results for the platelets.
On patients with clumping what you will see on the post vortex is a
decrease in the WBC and an increase in platelets. Once again you
need to confirm with a smear. Why would you see a decrease in
WBC? The clumps were counted as WBC. For reporting all results
from the pre-vortex sample are reported except the WBC and Platelet
and instrument differential. The vortex WBC and platelet replace the
original if all clumping is gone. Of course if you need a differential on
this sample it should be performed manually.
Suhair.A.A./ Quality Assurance / 3rd
year 40
 Suhair.A.A./ Quality Assurance / 3rd
41 year
Post Analytical Example 2
 Laboratory Results
 WBC - 8,500/uL  Instrument Differential
 RBC - 4,870,000/uL
 Neutrophil% - 60.9%
 Lymphocyte % - 28.7%
 Hgb - 16.4 g/dl
 Monocyte % - 8.2%
 HCT - 43.5%
 Eosinophil% - 2.0%
 Platelets - 356,000/ul
 Basophil% - 0.2%
 MCV - 89.5 fl
 Flags
 MCH - 23.6 pg
 H-H difference check
 MCHC - 37.7 g/dl
 Alert (aH) on the MCHC
 RDW -12.5%
 Spun HCT – 44%

Suhair.A.A./ Quality Assurance / 3rd

year 42
The patient is a 54 year old man. A routine CBC was
drawn in the out-patient department and it was run on a
Coulter LH750.
The technologist reviewed the instrument CBC,
automated Diff and flags
These are the problems that were noted –
MCHC > 36.0
H&H Check Flag - H & H does not pass rule of three
(three times the HGB should equal the HCT +/- 3)
The laboratory policy is to spin a Hematocrit on any
MCHC >36.0
The Spun hematocrit matches the hematocrit from the
instrument.
Therefore, the HGB is the incorrect parameter –

Suhair.A.A./ Quality Assurance / 3rd

year 43
What is the Explanation ?

Spun Plasma
◼ The MCHC is > 36
◼ The spun hematocrit matches the
instrument
◼ It would appear that the Hgb is
incorrect
◼ Lipemia will falsely increase the
hemoglobin result
◼ Follow laboratory policy for lipemic
samples

Suhair.A.A./ Quality Assurance / 3rd

year 44
Post Analytical Example 3
 Laboratory Result 1  Laboratory Result 2
 WBC - 8,500/uL  WBC – 8,300/uL
 RBC - 4,870,000/uL  RBC – 4,000,000/uL
 Hgb - 16.4 g/dl  Hgb – 16.2 g/dl
 HCT – 48.2%  HCT – 36.0%
 Platelets - 356,000/ul  Platelets – 340,000/uL
 MCV - 89.5 fl  MCV – 90.0 fl
 MCH - 33.7 pg  MCH – 40.5 pg
 MCHC – 34.0 g/dl  MCHC – 45.0 g/dl
 No flags  H-H difference check
 Delta Check on HCT
and MCHC

Suhair.A.A./ Quality Assurance / 3rd

year 45
When we look at the spun hematocrit this is what it
looks like. It shows that the sample is hemolyzed.
A Hemolyzed sample would causes a decrease in
the RBC count which in turn would affect the HCT
result. Hemolysis would not affect the Hgb or MCV
so it will cause an increase in the MCHC. It also
affects the MCH result.

Suhair.A.A./ Quality Assurance / 3rd

year 46
 Suhair.A.A./ Quality Assurance / 3rd
47 year
Post Analytical Example 4
 Laboratory Result 1  Laboratory Result 2
 WBC – 6,300/uL  WBC – 6,800/uL
 RBC – 2,321,000/uL  RBC –3,475,000 /uL
 Hgb – 6.5 g/dl  Hgb – 9.5 g/dl
 HCT – 19.5%  HCT – 28.5%
 Platelets - 250,000/ul  Platelets – 240,000/uL
 MCV - 75 fl  MCV – 82 fl
 MCH – 28.0 pg  MCH – 29.0pg
 MCHC – 33.3.0 g/dl  MCHC – 34.3.0 g/dl
 RDW – 9.8  RDW – 13.4
 Delta Check on Hgb,
HCT, and MCV

Suhair.A.A./ Quality Assurance / 3rd

year 48
◼ The patient is a 32 year old female. Two routine
CBC was drawn a week apart in the out-patient
department and it was run on a Coulter LH750.
◼ The technologist reviewed the instrument CBC,
automated Diff and flags
◼ We have some differences

◼ We have Delta Checks on the Hgb, Hct, MCV,

and MCHC. Any possible explanations?

Suhair.A.A./ Quality Assurance / 3rd

year 49
 Suhair.A.A./ Quality Assurance / 3rd
50 year
Analytical Control

• Internal Quality Control

• External Quality
Assessment
Suhair.A.A./ Quality Assurance / 3rd
year 51
 INTERNAL QUALITY CONTROL

Suhair.A.A./ Quality Assurance / 3rd

52 year
Internal Quality Control includes

• Daily control specimen

➢ Commercial Control
➢ Patient Control

• Correlation/Comparison System
• Policy- QC and Troubleshooting

Suhair.A.A./ Quality Assurance / 3rd

53 year
Internal Quality
Control
Commercial Controls

Suhair.A.A./ Quality Assurance / 3rd

year 54
Commercial Controls

◼ Assayed vs Non-assayed

◼ Introducing New QC Lot

◼ Establishing QC Ranges

Suhair.A.A./ Quality Assurance / 3rd

55 year
Establishing Means and Standard
Deviations
1. Analyze the control(s) a minimum of 20 times across several
days.
2. Take the average of these runs.
3. The average should be within the range state on the assay
sheet.
4. Calculate a two Standard Deviation range from your results.
5. Incorporate this SD range around your new mean and
monitor.
6. The mean and SD values should be periodically recalculated
during the life of the new lot.

Suhair.A.A./ Quality Assurance / 3rd

56 year
Factors to Consider for Means
◼ Some hematology parameters, such as MCV,
Platelets and RBC will start to change over
time.
◼ MCV will increase.
◼ RBC values can decrease.
◼ Platelets values will increase.
◼ Mean, SD, and CV should be evaluated
monthly.
Suhair.A.A./ Quality Assurance / 3rd
57 year
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 9 8 8
1 0 2 4 5 6 3 2 1 3 4 5 3 5 4 3 1 3 5 4 3 5 6 5 4 5 6 3 5 5 4 5 6 6 5 6 5 6 7 6 7 6 7 8 8 9 5 6 7 8 9 6 7 8 9 0 8 9 85.20

Suhair.A.A./ Quality Assurance / 3rd

58 year
QC Example 2
◼ Manufacturer RBC mean – 2.29 x 106
◼ Manufacturer RBC Range – 2.18-2.40 x 106
◼ Calculated RBC mean – 2.35 x 106
◼ Is this mean valid?
◼ Our 2SD = 0.15 x 106
◼ Calculated RBC range – 2.20-2.50 x 106
◼ Yes mean within the expected range.

Suhair.A.A./ Quality Assurance / 3rd

59 year
QC Example 3
◼ Manufacturer Platelet mean – 528 x 103
◼ Manufacturer Platelet Range – 407- 649x 103
◼ Calculated Platelet mean – 402x 103
◼ Is this mean valid?
◼ No below the expected range.

Suhair.A.A./ Quality Assurance / 3rd

60 year
Commercial Control
Monitoring
Levey-Jennings Charts

Suhair.A.A./ Quality Assurance / 3rd

year 61
Levey-Jennings QC Charts

Suhair.A.A./ Quality Assurance / 3rd

year 62
Trend

Suhair.A.A./ Quality Assurance / 3rd

year 63
First we will look at a Trend. A trend occurs when
five or more values show a gradual increase or
decrease. The values do not have to be out of your
acceptable range but this pattern can indicate that
a problem exists. Because hematology controls are
cell-based, some trending in sizing parameters can
be expected.

Suhair.A.A./ Quality Assurance / 3rd

year 64
Shift

Suhair.A.A./ Quality Assurance / 3rd

year 65
Next we have a Shift. This is when there is a
sudden change in control results from one run or
day to the next. A shift does not always mean
that a problem exists. What are some reason
you might get a shift? Instrument calibrated.
Service performed.

Suhair.A.A./ Quality Assurance / 3rd

year 66
Bias

Suhair.A.A./ Quality Assurance / 3rd

year 67
Finally we have a bias. A bias is when the control
starts running on one side of the mean. It can occur
with just one or all of your controls. If it is only one of
your control can indicate a problem with just that
level. If it is across all the controls than can indicate
an instrument problem or the need to calibrate.

Suhair.A.A./ Quality Assurance / 3rd

year 68
QC Policy

◼ Each laboratory should adopt QC rules.

◼ Establish policy/corrective action for
controls that are “Out”.
➢ Documentation is important.
◼ Establish policy for Trends, bias and shifts.
◼ Establish when calibration are required.

Suhair.A.A./ Quality Assurance / 3rd

69 year
 Thanks

Suhair.A.A./ Quality Assurance / 3rd

year 70