Quality control in low budget

laboratories – pooled serum and

retained patient samples as
alternative qc material

By safinaz ghareeb talab

Deputy quality manager for clinical
laboratories –central public health
laboratories ministry of health
objectives
QUALITY CONTROL IN MEDICAL
LABORATORIES
 definitions
• In the laboratory, quality is defined as a process
that ensures customers receive products free
from defects and meet their needs
• Quality control (QC) is a functional practice in the
clinical laboratory and is a routine and mandatory
task. QC encompasses the analysis of QC
materials and comparison of the observed values
to the expected distribution under stable
operating conditions.
• Process control is one of
12 quality system
essentials developed by
CLSI and followed by all
laboratory standards
 Types of quality control
Internal quality control External quality control

• it is the use of control • it describes a method that

samples and statistical
methods to monitors the
daily performance of
methodologies, personnel,
and instruments ad
environmental conditions
allows the comparison of a
laboratory’s performance to
a source outside the
laboratory, such as a peer
group of laboratories or a
reference laboratory.

Neither internal nor external quality control

should be the only quality control process
 Role of quality control on lab
performance

internal external

•Mainly •Mainly
monitor monitor
precision trueness
QUALITY CONTROL IN DIFFERENT
STANDARDS
General Authority for Healthcare Accreditation
and Regulation (GAHAR) standards

• TEQ.01 An internal quality control plan is developed and

implemented for all laboratory tests
• TEQ.02 Internal quality control data are reviewed at regular interval
• TEQ.03: Proper corrective actions are taken upon quality control
result violation(s).
• TEQ.04 The laboratory participates in an external quality
assessment program.
• TEQ.05: Proficiency testing specimens are integrated within the
routine laboratory workflow.
• TEQ.06 Alternative assessment procedure(s) (AAPs) are performed
for tests that are not included in the external quality assessment
program.
Iso 15189:2012
 Egyptian standard for
• 8182
 Quality control materials

• QC materials act as surrogates for clinical samples and

are measured in laboratories on a daily basis in the
same manner as patient specimens.
• QC materials are commercially available in liquid or
lyophilized form, and are usually packaged in bottles
that enable routine and repeated use.
• Laboratories can obtain QC materials from the same
manufacturer as the equipment and/or reagents that
the laboratory uses, or purchase them from third-party
vendors that specialize in producing QC materials.
Types of qc materials
In-house
commercial
prepared
Qualitative
• Reference strains CRM -Spiked in
sample matrix

Quantitative
• Assayed material Retained patient
• Unassayed material samples

Pooled serum
 Types of qc materials
• Control materials Controls are substances that contain an established amount of the substance being tested—the
analyte. Controls are tested at the same time and in the same way as patient samples. The purpose of the control
is to validate the reliability of the test system and evaluate the operator’s performance and environmental
conditions that might impact results. It is important not to confuse calibrators and control materials. Calibrators
are solutions with a specifi ed defi ned concentration that are used to set or calibrate an instrument, kit, or system
before testing is begun. Calibrators are often provided by the manufacturer of an instrument. They should not be
used as controls since they are used to set the instrument. Calibrators are sometimes called standards, but the
term calibrator is preferred. They usually do not have the same consistency as patients’ samples. It is critical to
select the appropriate control materials. Some important characteristics to consider when making the selection
are: Controls must be appropriate for the targeted diagnostic test—the substance being measured in the test
must be present in the control in a measurable form. The amount of the analyte present in the controls should
be close to the medical decision points of the test; this means that controls should check both low values and high
values. Controls should have the same matrix as patient samples; this usually means that the controls are serum
based, but they may also be based on plasma, urine or other materials. Because it is more effi cient to have
controls that last for some months, it is best to obtain control materials in large quantities. Control materials are
available in a variety of forms. They may be frozen, freezedried or chemically preserved. The freeze-dried or
lyophilized materials must be reconstituted, requiring great care in pipetting in order to ensure the correct
concentration of the analyte. Control materials may be purchased, obtained from a central or reference
laboratory, or made in-house by pooling sera from different patients. Purchased controls may be either assayed or
unassayed. Assayed controls have a predetermined target value, established by the manufacturer. When using
assayed controls, the laboratory must verify the value using its own methods. Assayed controls are more
expensive to purchase than unassayed controls. When using either unassayed or “in-house” controls, the
laboratory must establish the target value of the analyte.
 Assayed QC Materials
• Assayed QC materials have analytes values
specified in the labeling by the manufacturer.
• These analytes values and associated ranges
are provided as guidelines to the end user.
• the clinical laboratory establishes its own
ranges based on its own test system and
criteria.
 Unassayed QC Materials
• The manufacturer may indicate whether a
specific analytes is present or absent in the QC
material preparation without indicating an
expected assay result.
• The end user, rather than the manufacturer
assigns expected results to Unassayed QC
material.
• While manufacturing of a QC material should
include some type of analytes level assessment as
part of the production process, such as high ,
moderate and low control.
in-house prepared control material
• The use of in-house controls requires
resources to perform validation and testing
steps.
• its advantage is that the laboratory can
produce very large volumes with exact
specifications.
• Universal precautions should be used when
handling.
COST BENEFIT ASSESSMENT OF QC
LOW BUDGET LAB IMPASSE
 Low budget lab problems
• Qc material is not an independent item in The
Egyptian Authority for Standardized
Procurement and Medical Supply system
• Delayed shipments
• low to moderate flow rate
• Expensive qc material
• Short expiration interval as In hematology
How do we overcome this problem?!!!!
 1- develop a Qc program
• steps for implementing and maintaining a QC
program include:
• establishing written policies and procedures,
including corrective actions
• training all laboratory staff
• ensuring complete documentation
• reviewing quality control data.
2- Qc procedure adjustments Based on
Risk Management

• Clsi EP 23-A provide users with the guidance

needed to “develop effective, cost-efficient QC
protocols that will ensure appropriate lab
performance
• Lab has to define:
– the number of levels of QC material to be assayed for
each analytes.
– analytical run length, and in turn, frequency of QC
material analysis.
3-Establishing analytical run length
• There is no standard protocol or guideline to establish analytical run
length, so practice varies across different laboratory settings. Labs
should define these parameters based on:
– the expected stability of the analytical system.
– the number of patient specimens analyzed.
– cost of sample repetition.
– access to patient data in the event of QC failure.
– Workflow patterns.
– internal resource capabilities.
– the clinical impact of undetected errors that may occur before the
next QC measurement
All are important considerations in determining the analytical run length
and frequency of QC material analysis.
4- Selection of quality control material
• Select values that cover medical decision
points in the medically significant range.
• Assayed material is preferred as it evaluate
accuracy of the process( consider that it is
much more expensive than Unassayed
material)
• In case of unavailability of commercial quality
control material consider in-house prepared
material or retained patient samples.
CPHL EXPERIENCE IN PCR UNIT

POOLED SERUM QC MATERIAL FOR

PCR
Preparing and storing control material

Key steps in the preparation of a typical quality control

material
Inclusion criteria
 Testing homogeneity

• It is important to confirm the consistency of the filling

procedure and to confirm that the bulk was dispersed
(for example, stirred) sufficiently throughout.
• Homogeneity is assessed in two ways – by determining
both the biological and the physical content (weight or
volume) of multiple vials across the batch.
• It is also important to determine the biological
homogeneity by assessing the concentration of the
analyte in multiple vials across the batch.
• The number of vials used for testing will depend on the
batch size. As a minimum, typically 1–2% of the vials
should be tested.
 Calculation of uncertainty of
measurement
• The assignment of an uncertainty value must be applied to
reference materials. The uncertainty – often referred to as
“measurement uncertainty” (MU) – expresses the 95%
confidence limits either side of the observed value assigned
to a product.
• By estimating the MU of a product the confidence in the
final value assigned is shown. Uncertainty should be
calculated using log-transformed data.
• For example, a value of 3 log10 IU/mL may be assigned to a
standard. Following estimation of uncertainty this value
may be displayed as 3 log10 IU/mL ± 0.2 – that is, the value
of the material could range from 2.8–3.2 log10 IU/mL.
• The lab use the usual method for calculating uncertainity
Calculation of qc material specification
data
• In each run, the precision of the analytical process is
determined by the analysis of aliquot of control
material. Here we assume that "day" and "run" are
similar.
• Continuity is maintained through at least 20
overlapping runs in which replacement control pools
are analyzed concurrently with "old" control pools.
• Calculation of quality control limits:
The run or daily mean, x , for each control level is calculated
for each run by dividing the sum of control values in the run
by the number of control samples, n, per run.
• The standard deviation of the run means, SD , is
calculated for each control. The equation for
calculating the standard deviation of the run means is
as follows:

• The warning (95% probability) limits for the x - chart:

• Upper warning limit = X + 2SD
• Lower warning limit = X - 2SD
 Stability testing
• A stability testing program should be implemented to monitor the potency of the
• RM over time. Stability monitoring can be based on real-time data.
• Stability testing:
• - After developing control range in valid runs, samples was tested for stability
• by assessing its value across time.
• - A stability study was done by testing the quality control results every week
• and confirm its value regarding a acceptable commercial quality control in
• the same run, across ten weeks the quality control pooled plasma was tested
• and validated as long as the results fall between 3SD, in the tenth week the
• results of low level pooled control fall below the third SD.
• Our procedure accept the quality control results for 9 weeks only according to the
stability study results.
USE OF RETAINED PATIENT SAMPLE
FOR HEMATOLOGY
• Use of retained patient specimens alone is
inadequate for routine QC of the primary CBC
instrument, and must be considered as a
supplemental procedure
• Written QC procedure defining the control
limits for repeat analysis of retained patient
specimens AND ✓ QC records showing the use
of the defined control limits
 hematology
• RETAINED PATIENT SPECIMENS can be used for
the quality control of hematology analyzers. A
tabular record of the RBC and WBC counts
simplified the evaluation of between- and within-
technologist performance. As
ethylenediaminotetraacetate (EDTA)
anticoagulated blood specimens were stable
when refrigerated overnight. They recommended
the quality control practice of reanalyzing five
patient specimens stored overnight and
comparing their new average with the previous
average
• most hematology parameters are stable over at least 40
hours,platelets and WBCs are less stable in retained specimens
compared with commercial controls
• three normal range patient specimens be retained after initial
analysis and reanalyzed at regular intervals, e.g., every eight hours.
After each reanalysis, differences between the initial and the
replicate determinations should be calculated and compared with
the ±2 s limits. If two specimens exceed these limits for any test,
there is a high probability of analytic error in that test.
• Use of specimens that are significantly higher in concentration will
result in a higher than expected false rejection rate. Similarly, use of
low-level specimens will result in a lower Ped. Because of this
degradation in performance characteristics, we recommend the use
of normal range specimens.
 references
• CLSI. Laboratory Quality Control Based on Risk Management;Approved
Guideline. CLSI document EP23-A. Wayne, PA:Clinical and Laboratory
Standards Institute; 2011.
• CLSI. Understanding the Cost of Quality in the Laboratory; A Report. CLSI
document QMS20-R. Wayne, PA: Clinical and Laboratory Standards
Institute; 2014.
• ISO GUIDE 80:2014 Guidance for the in-house preparation of quality
control materials (QCMs)
• Use of Patient Samples for Quality Control in Hemogram: An Experience
from a Tertiary Care Centre in Southern India.Annals of Pathology and
Laboratory Medicine, Vol. 6, Issue 6, June, 2019 .
• Laboratory quality management system: handbook. World Health
Organization. ISBN 978 92 4 154827 4
• WHO manual for the preparation of secondary reference materials for in
vitro diagnostic assays designed for infectious disease nucleic acid or
antigen detection: calibration to WHO International Standards
 references
• ISO 15189:2012Clause5.6 Assuring quality of examination procedures
• CLSI C24: Statistical QC for Quantitative Measurements
• CLSI GP 29A
• CAP All-Common Checklist, 2015
• WHO manual for the preparation of secondary reference materials for in vitro diagnostic
• assays designed for infectious disease nucleic acid or antigen detection: calibration to
• WHO International Standards.
• Resolution WHA63.12. Availability, safety and quality of blood products. Sixty-third
• World Health Assembly, Geneva, 17–21 May 2010. Geneva: World Health
• Organization; 2010 (http:// apps.who.int/gb/ebwha/pdf_ les/WHA63-
• REC1/WHA63_REC1-en.pdf, accessed 7 February 2017).
• CLSI. Characterization and quali cation of commutable reference materials for
• laboratory medicine; approved guideline. CLSI document EP30-A. Wayne (PA):
• Clinical and Laboratory Standards Institute; 2010 (sample:
• http://shop.clsi.org/site/Sample_pdf/EP30A_sample.pdf, accessed 7 February 2017).