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What is quality control?
An attempt to control and monitor a process to ensure a consistent outcome.
Why perform quality control in a medical laboratory ?
Because we need something to do before the samples arrive
The charts are pretty
Gives the QC officer a reason to come to work
Because the results we produce have a DIRECT effect on the lives of those patients who use our services
Patient• Education• Compliance• Health• Drug
interactions
Dosing Process• DAWN• DR experience
INR
Components for making warfarin therapy safe and effective.
Lab errors measuring PTT’s and INRs linked to bleeding, deaths at hospital.
Reuters Health Information 2003 2003 Reuters Ltd.
Errors in determining prothrombin time began when employees in the lab did not notice that they had been sent an old reagent, and used an incorrect ISI to calculate the INT. Dr Lurie said “they plugged the wrong number into their calculations”
Due to the errors, the lab produced more than 2,000 INR readings that were falsely low. Patients tested during the time of the errors were more likely to experience bleeding complications. Three patient deaths were attributable to the mistake.
The Sample Collection technique Contamination by heparin or saline flushes Ratio of blood to anticoagulant (9:1) Low HCT causes change in final citrate
concentration Adequate mixing of sample without frothing Transportation to testing facility
- delay in testing Clotted, haemolysed, icteric or lipaemic
specimen Incorrectly or unlabelled sample
Sources of error in the coagulation lab.
Change in INR vs Storage Time
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
0 1 2 3 4 5 6 7 8
Storage Time ( Days)4oC
Ch
ang
e In
INR
Change in INR vs storage time
Storage time (days) 40C
Ch
ang
e in
INR
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
Reagent related problems Selection of an appropriate reagent
Contaminated reagents
Reconstitution with incorrect volumes
Reconstitution with incorrect diluent
Defects in product due to mishandling in shipping and storage
Reagent used beyond stated stability or expiration date
Contaminated water used for reconstitution
Analytical Errors
Incorrect value assignment
( ISI , MNPT or std value)
Incorrect incubation or activation time
Incorrect or imprecise dispensing of reagents
Failure to use proper instrument operating procedures
Extrapolation beyond readable limits of reference curve
Failure to action instrument warning flags
Instrument Failure Defective light source or detection system
Incorrect temperature
Poor reagent / sample delivery
Electrical Interferences
Reagent splash
Mechanical failure, e.g. reagent stirring etc
Internal –
Daily Verify I, II, III for PT, INR, APTT, Fib
Should be run minimum daily or every 8 hours or every 40 samples or with new bottle of reagent
Patient samples should not be tested until QC accepted
If fails , retest by elimination until fault found
External –
Monthly central review of Mean, SD of daily review
RCPA (and central review of)
Quality control
2003COAG Veri fy Monthly QC Jul-03
INR=F0000 Veri fy 1FIB=F1080
PT INR APTT FIBLab Mean SD Mean Mean SD Mean SD V1 V2 V3 Th/plas t in Platelin LS
ACL BSA 13.38 0.24 0.97 28.57 0.35 2.44 0.10 161675 161728 161688 1220205 111091PT=F0015 BUN 13.04 0.22 0.99 28.35 0.38 2.84 0.13 161672 161679 161688 1220205 111091APTT=0200 COF 12.89 0.16 0.95 28.45 0.77 3.15 0.20 161672 161728 161688 1220205 111091
GPH1GPH2GRF 13.17 0.30 0.99 27.63 0.83 2.98 0.20 161672 161679 161688 N1220205 111091HER 13.34 0.22 1.01 28.30 0.51 2.56 0.23 161675 161728 161688 1220205 111091MAR 13.26 0.31 1.03 28.70 0.65 2.76 0.21 161675 161728 161688 1220205 111091MPR 13.46 0.30 1.02 28.48 1.12 2.93 0.17MYB 13.42 0.22 1.00 29.17 0.30 2.95 0.14 161675 161728 161688 1220205 111091TSV 13.00 0.50 0.98 28.50 1.11 3.06 0.25 161675 161728 161688 1220205 111091Mean 13.2 1.00 28.5 0.6 2.8 0.2SD 0.2 0.4 0.2
CA540 CAIPT=0020 GPHAPTT=0200 LIS 10.68 0.33 1.01 27.75 0.64 2.52 0.69 161675 161728 161688 828542 111091
SPT 12.90 9.00 1.10 31.52 12.75 2.86 0.32 161675 161728 161688 828542 111091TPL 14.80 1.10 1.00 27.40 0.50 2.90 0.30 161672 161679 161625 828542 111091TSA 10.70 0.40 1.00 27.00 55.10 3.19 0.22 161675 161728 161658 828542 111091TUGW ES
CA1000 TPL 16.00 2.60 1.02 29.80 1.20 3.35 0.20 161672 161679 161625 828542 111091CA6000 ROC 10.30 0.40 1.00 30.60 0.80 3.19 0.10 161672 161728 161688 828542 111091
Mean 13.02 2.69 1.03 28.69 14.04 2.96 0.35SD 2.41 0.04 1.88 0.30
STA Taringa 11.90 0.16 1.00 30.10 0.67 3.58 0.15 161672 161728 161688 828542 111091STAR Taringa 12.20 0.23 1.00 XX XX XX XX 161672 161728 161688 828542 111091
Manual GLA 12.07 0.47 1 34.45 1.69 161675 161728 161688 828542 111091
Feb 03 Verify QC-INR
0. 00
0. 50
1. 00
1. 50
2. 00
2. 50
3. 00
3. 50
4. 00
4. 50
5. 00
Verif y I
Verif y I I
Verif y I I I
RCPA
Royal College of Pathologists
Haematology QAP- Haemostasis POC care – INR module INR, APTT, Fibrinogen and D-Dimer Special Haemostasis
Thrombophilia
von Willebrand testing
NATA
National Accreditation and Testing Authority Primary function is Proficiency testing Peer review of all technical processes Licence to provide pathology services Regular review every 3 years Corporate surveillance
NATA Assessment
Relevant documentation( including its currency) Appropriateness of methods and procedures Suitability of equipment or instruments ( incl calibration ) Suitability of environment and supporting services Adequacy of personnel ( number, training, skills etc) Monitoring of processes / quality control measures Handling and identification of test specimens or test items Recording and reporting of results –documentation control
ISO9001/ IEC 17025
Traceability and accountability Quality systems ( Documentation) Non conformance
Complaints ( Internal and External) Classification and review of NCie Why did this error occur ? Random or system error Corrective or preventative actions
Audits – allows regular review of all processes. Horizontal Vertical
So the aim for laboratory staff…
Produce consistent results,consistently
Pay attention to what is happening
(eg new lot numbers)
Don’t assume it will be alright eventually.
Don’t assume it is someone else’s responsibility.
Trace ability and accountability.
Action faults efficiently and effectively.
Pro actively prevent faults by doing instrument maintenance