Laboratory

Quality Control
USE AND NEED OF QUALITY
CONTROL IN A CLINICAL
LABORATORY
OBJECTIVES
1. Students will be able to define Quality Control and
Quality Assurance , so that when ask would recall with
100% accuracy.
2. Student will be able understand the importance of
controls and be able to differentiate among them, so
that when ask would be able to state the importance of
each and identify the difference from other controls
with 100% accuracy.
3. Students will be able to establish the difference
between random errors and systematic errors, so the
when ask would state so accurately.
OBJECTIVES
4. Students will be able to understand the concept of
trouble shooting , so that when given a scenario would
correctly state the use and purpose of trouble
shooting.
Definitions
Quality Control - QC refers to the measures that
must be included during each assay run to verify
that the test is working properly.
Quality Assurance - QA is defined as the overall
program that ensures that the final results reported
by the laboratory are correct.
Definitions
Quality Assessment - quality assessment (also
known as proficiency testing) is a means to
determine the quality of the results generated
by the laboratory.

Quality Assessment may be external or internal.
Variables that affect the quality of
results
The educational background and training of the
laboratory personnel
The condition of the specimens
The controls used in the test runs
Reagents
Equipment
The interpretation of the results
The transcription of results
The reporting of results
Internal controls
Verify the internal control function for each sample
processed.
If an internal control fails, the sample must be repeated.
Examples of failure causes are
Improper sample addition
Faulty device
External controls
Kit (manufacturer prepared) controls (all tests):
Must be performed:
With each new lot or lot change.
With each new shipment.
When temperatures exceed the manufacturer
recommended storage conditions.
With each new operator prior to performing testing on
patient specimens
With each processor/equipment daily.
Controls run on every testing day
Store and use according to manufacturer recommendations.
Data is recorded in the QC log book located in the
laboratory.
In-house controls
Must be performed:
With each new lot or lot change.
With each new shipment.
When temperatures exceed the manufacturer
recommended storage conditions.
With each new operator prior to performing testing
on patient specimens.
Refer to procedures regarding preparation of in-house
controls and their storage.
Data is recorded in the QC log book and the containers
for that lot or shipment are labeled Ready to Use.
Numeric value QC


When the method is put into service, you also establish
your own means and standard deviations (SDs) for
control materials.

A validated chart is generated using 20 or more
measurements. Once the chart is plotted the mean and
the standard deviations (1s, 2s and 3s) are calculated
using excel program.
Numeric value QC (cont.)



If it becomes evident that the mean needs to be adjusted
due to shift change, lot change or reagent change, a QC
Chart Change Form should be completed and filed in the
appropriate QC binder.

When there are changes in the source or lot numbers of
control materials, it is important to carefully establish the
means and SDs for the new materials while the old
materials are still in use.
Numeric value QC (cont.)

The control limits are supposed to describe the
variation expected when performance is stable, i.e.,
when there are no problems occurring. Therefore, it
is advisable to eliminate all control values from all
runs that have been rejected, even if some of those
control values are within 2 SD of the mean.
Errors in measurement
True value - this is an ideal concept which
cannot be achieved.

Accepted true value - the value approximating
the true value, the difference between the two
values is negligible.

Error - the discrepancy between the result of a
measurement and the true (or accepted true
value).

Sources of error
Input data required - such as
calibration values and values of
physical constants.

Inherent characteristics of the
quantity being measured

Instruments used - accuracy,
repeatability.
Observer fallibility - reading errors,
blunders, equipment selection,
analysis and computation errors.
Environment - any external
influences affecting the
measurement.
Theory assumed - validity of
mathematical methods and
approximations.

Random Error

An error which varies in an unpredictable manner, in
magnitude and sign, when a large number of
measurements of the same quantity are made under
effectively identical conditions.

Random errors create a characteristic spread of results for
any test method and cannot be accounted for by applying
corrections. Random errors are difficult to eliminate but
repetition reduces the influences of random errors.

Random Errors


x


x x
x x
True x x x x
Value x x x
x x x
x
x

x


Systematic Error


An error which, in the course of a number of measurements of the
same value of a given quantity, remains constant when
measurements are made under the same conditions, or varies
according to a definite law when conditions change.

Systematic errors create a characteristic bias in the test results and
can be accounted for by applying a correction.

Systematic errors may be induced by factors such as variations in
incubation temperature, change in the reagent batch or
modifications in testing method.

Systematic Errors
x
x x x x x x x
True x
Value
Levey-Jennings Chart
Include the name of the test and the name of the control
material in a prominent place so that this information is
quickly and easily discerned when viewing the chart.
The measurement unit can be included in the label or
included in the label for the y-axis.
Other information included in the cover sheet accompanying
the charts are the lot number of the control material, the
current mean and standard deviation, and the time period
covered by the chart.
The horizontal or x-axis represents number of run.
The vertical or y-axis represents the observed control value
and is set to accommodate the lowest and highest results
expected.
On the y-axis, locate the values that correspond to the mean and
draw a horizontal line. The mean is calculated by adding all the
measurements for a particular control and dividing that sum by the
number of points. Excel can be used to determine this by
highlighting the values and calculating the mean.

Westgard rules

Westgard rules are commonly used to analyze
data in Shewhart control charts.
Westgard rules are used to define specific
performance limits for a particular assay and
can be use to detect both random and
systematic errors.
There are six commonly used Westgard rules
The violation of warning rules should trigger a
review of test procedures, reagent
performance and equipment calibration.

The violation of mandatory rules should result
in the rejection of the results obtained with
patients serum samples in that assay.


Shewhart Control Charts
A Shewhart Control Chart depend on the use of IQC
specimens and is developed in the following
manner:-

Put up the IQC specimen for at least 20 or more
assay runs and record down the cut-off value or
antibody titre (whichever is applicable).
Calculate the mean and standard deviations (s.d.)
Make a plot with the assay run on the x-axis, and
cut-off or antibody titre on the y axis.
Draw the following lines across the y-axis:
mean, -3, -2, -2, 1, 2, and 3 s.d.
Plot the cut-off obtained for the IQC
specimen for subsequent assay runs
Major events such as changes in the batch
no. of the kit and instruments used should
be recorded on the chart.

Shewhart Chart
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
+3 sd
-3 sd
+2 sd
-2 sd
-1 sd
+1 sd
VZV IgG ELISA: Target Value = 49 U/ml
A
n
t
i
b
o
d
y

U
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Target value
Assay Run
Warning rules

Warning 1
2SD
: It is violated if the IQC value exceeds the
mean by 2SD.

Warning 2
2SD
: It detects systematic errors and is violated
when two consecutive IQC values exceed the mean on the
same side of the mean by 2SD.

Warning 4
1SD
: It is violated if four consecutive IQC values
exceed the same limit (mean 1SD) and this may indicate
the need to perform instrument maintenance or reagent
calibration. Systematic error.
Mandatory rules

Mandatory 1
3SD
: It is violated when the IQC value exceeds
the mean by 3SD. The assay run is regarded as out of control.
Random error.

Mandatory R
4SD
: It is only applied when the IQC is tested
in duplicate. This rule is violated when the difference in SD
between the duplicates exceeds 4SD. Random error.

Mandatory 10x : This rule is violated when the last 10
consecutive IQC values are on the same side of the mean or
target value.

Westgard Rules: 1 3SD
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
+3 sd
-3 sd
+2 sd
-2 sd
-1 sd
+1 sd
VZV IgG ELISA: Target Value = 49 U/ml
A
n
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b
o
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y

U
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Target value
Assay Run
Westgard Rules: 10X
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
+3 sd
-3 sd
+2 sd
-2 sd
-1 sd
+1 sd
VZV IgG ELISA: Target Value = 49 U/ml
A
n
t
i
b
o
d
y

U
n
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Target value
Assay Run
Monitoring Frequency
Weekly
Each day an assay is performed, the days results are
plotted on the appropriate weekly chart and
checked by the analyst after entry.
The supervisor and/or quality assurance manager or
their designee check the weekly chart at the end of
the week.
Monthly
Values from the month are compiled and reviewed
by the supervisor and/or quality assurance manager
or their designee at the end of the month.
Follow-up action in the event of a violation
There are three options as to the action to be taken in the event
of a violation of a Westgard rule:

Accept the test run in its entirety - this usually applies
when only a warning rule is violated.
Reject the whole test run - this applies only when a
mandatory rule is violated.
Enlarge the greyzone and thus re-test range for that
particular assay run
Trouble shooting Out-of-Control runs.
Systematic errors may be caused by factors such
as a change in reagent lot, improperly prepared
reagents, deterioration of reagents, inadequate
storage of reagents, change in sample reagent
volumes due to pipettor maladjustments or
misalignment, change in temperature of
incubators and reaction blocks, deterioration of
photometric light source, and change in
procedure from one operator to another.
Trouble shooting Out-of-Control runs.
Random errors may be caused by factors such as
inadequately mixed reagents, unstable temperature
and incubation, unstable electrical supply, and
individual operator variation in pipetting, timing, etc.





Relate causes to recent changes.




Systematic errors are most often related to reagent or
calibration problems. A sudden shift is usually due to a
recent event such as replacement of reagent,
introduction of a new reagent lot number, or a recent
calibration. When a shift is identified, the operator
should inspect the reagent, calibration, and
maintenance records for clues to resolving the problem.
Relate causes to recent changes.

A systematic trend can be more difficult to resolve
than a shift, simply because the problem is occurring
over a longer period of time.
Review QC records, including documentation of
function checks. Trends can be the result of a slowly
deteriorating reagent, a change in instrument
temperature, or a deteriorating filter or lamp.
Use a systematic logical trouble-shooting approach in
isolating the cause, making only one change at a time
and documenting each action taken.

Relate causes to recent changes
Problems resulting in increased random error are much more
difficult to identify and resolve, mostly due to the nature of the
error, which cannot be predicted or quantified as can systematic
error.
Random errors are more likely due to improperly mixed reagents,
pipette tips not fitting properly. A clog in the pipettor, imprecise
pipettor, the power supply, and even power fluctuations. Many
of the sources of random error can be observed by physical
inspection of the analytical method during operation. Careful
inspection of reagents and the sampling/reagent pick-up and
dispensing activities will often identify the cause of the problem.
If nothing is observed during the inspection process, consult
trouble-shooting guides and manufacturer recommendations.
Corrective Action
After the cause of the problem has been identified, it must
be corrected and the solution verified by retesting all of the
controls.
Once in-control, patient samples from the out-of-control
run should be repeated as necessary. The out-of-control
event must be documented using the Occurrence
Management Form.
Key operators can often recognize the most common
problems with a given system and are more skilled at
problem resolution than the infrequent operator. The
knowledge of these key operators should be tapped to
identify logical trouble-shooting approaches which can be
used by all operators.
Non-numeric value QC
These results are either a pass or fail for a particular
method.
If the run fails, further investigation into the cause is
necessary. Complete an Occurrence Management Form
and document the corrective action taken to resolve the
problem.
Kit controls are documented in the QC log book located
in the laboratory.
In-house controls are recorded on the reagent/kit log and
the lot is labeled Ready to Use.
QC Recording



What
A complete description of the process, i.e., the method procedure.
Initial evaluation data to document method performance.
Daily information about routine operation:
The analyst
Observed control values
Decisions made about the control value
Identification of any problems
Documentation of any corrective action
Evidence of supervisory review.
All individual data values
Summary statistics monthly and cumulative
QC problems and decisions
Trouble-shooting activities
Corrective actions and follow-ups
Proficiency testing results
Preventive maintenance scheduled and unscheduled
QC Recording
Reason for maintenance, what was done, by whom.
Frequency and length of downtime
Signs of instrument deterioration
Calibration, calibration verification scheduled and
unscheduled.
Lot numbers and expiration dates, what was changed, why, by
whom.
Reagent changes planned and unplanned.
Instrument function checks (temperatures, alignments,
gating, etc.).

QC Recording
How
The format for recording information must permit
convenient timely review by being clear, complete, and
well organized.
The record must be current and contain all the relevant
information.
Hard copies of all QC logs and/or charts are in the
laboratory binders.
QC records, reagent changes, calibrations, etc., are
retained at least two years, and all maintenance records
must be kept for the lifetime of the instrument plus two
years.
QC Recording
Who
The supervisor, lead analyst, or QA Manager is responsible for the
organization of the initial method evaluation study, but other
analysts may participate in the studies and be involved in collecting
the method performance data. A formal report of the method
evaluation can be found in the Validation binder.
Everyone who operates a method has the responsibility for recording
any changes they make to the testing process, control results they
obtain during operation, decisions on reporting or not reporting
patient test results, and corrective actions made.
The supervisor, their designee, or the QC specialist is responsible for
reviewing the daily QC, reviewing proficiency testing results,
following up on problems, reviewing the monthly QC statistics,
updating the cumulative QC statistics, identifying chronic and long-
term problems with the system, and recommending additional
studies, changes or improvements. These individuals may also be
responsible for reviewing method evaluation studies, selecting
appropriate QC procedures, and periodically reassessing or
validating the QC design.
QC Recording
When
Review QC records daily, weekly and monthly as well as
periodic quality audits.
These studies will aid trouble shooting and help correlate
daily performance data with information from method
evaluation experiments, proficiency testing surveys, and
patient test results.
Findings should lead to better preventive maintenance,
improved training of analysts, and redesign of
troublesome steps in the testing process.
HOME WORK
Define the terms trend and shift as it relates to QC
giving atleast two examples.
END