Quality Control

in Laboratory Medicine

by
Bashira Khalidy, MPH
Outline
Introduction
Consequences of Poor quality
Phases of Laboratory Quality
What is quality control
Objective of quality Control
Basis Statistics
Accuracy/Precision/Trends/Shifts
Random and Systematic Errors
Proficiency testing
Allowable Total Error
Westgard Rules
References

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 Introduction
From the first handling of test specimens and
paperwork, to the reporting of results, quality
should be monitored.

Attention to quality is paid every step of the way:

Test is ordered → Sample is collected → Test is run
→ Results are reported.

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Laboratory Testing
Impacts Nearly Everyone

Infant Child Teen Adult Senior

Accurate, reliable lab testing is essential to all
aspects of health care

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Phases of Laboratory Quality
1. Pre-Analytical Activities

2. Analytical Activities

3. Post-Analytical Activities

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Pre-Analytical
Where Quality Originates

Test ordering process

Patient preparation
Specimen collection procedures
Transport to the lab
Specimen handling and storage
Completeness of patient information

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Analytical Activities
Proceeding with Utmost Care
Instrument maintenance and operation
Test reagents
Supplies
Personnel
Actual test performance (Test method used)
Policies and procedures followed
Internal Quality control procedures
External Quality control /proficiency testing

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Post-Analytical Activities
Reporting with Quality

Organization of recording and reporting

Report sent to appropriate party
Timely reporting of data (Turnaround time)
Reference ranges included
Immediate notification of results exceeding
critical limits (Panic Values)

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The Quality Assurance Cycle

Patient/Client Prep
Sample Collection
Personnel Competency
Reporting Test Evaluations
Data and
Lab
Management
Safety
Customer  Sample Receipt
Service and Accessioning

Record
Keeping
Sample Transport
Quality Control
Testing

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Which Errors are Worse?

A question raised by the coexistence of pre-, post-, and

analytical errors is this:
Which ones affect the patients the most?
 - If you can't get the patient specimen to the lab,
 - If you can't perform the test correctly,
 - and if you can't deliver the results back to the
patient,
The consequence is the same: poor patient care.
No error is worse than the other.
They are all equally terrible.
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Analytical Phase
Instruments

Preventive & corrective maintenance for:

1. Equipment
2. Instruments: eppendorfs, incubators,
centrifuges, balances, thermometers,
automated pipettes and dispensers
3. Refrigerators: regular temperature monitoring

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Analytical Phase
Reagents

Always watch expiry date

Use components of reagent kits only with other kits

that are of the same lot number.

New lots of reagent must be checked against old lots,

or with suitable reference material, before or
concurrently with being placed into service.

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Reagents Cont’

Reagents (secondary containers) must be properly

labeled with the following elements:

Content and quantity

Concentration or titer
Storage requirements
Date prepared
Expiration date

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Analytical Phase Cont’

The need for day to day accuracy and precision is

the most important single problem encountered
by the medical technologist working in the lab.

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Analytical Phase Cont’
Daily QC is a process that is established to detect any
systematic errors that may interfere with reporting
patient samples.

It should serve as a baseline to verify that all

parameters on an automated instrument are correct
and in working order.

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What is Quality Control?

Quality control in the medical laboratory is a

statistical process used to monitor and evaluate the
analytical process that produces patient results.

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What is Quality Control?Cont’
QC results are used to validate whether the
instrument is operating within pre-defined
specifications, inferring that patient test results are
reliable.

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What is Quality Control? Cont’
Good laboratory practice requires testing normal and
abnormal controls for each test at least daily to
monitor the analytical process.

If the test is stable for less than 24 hours or some

change has occurred which could potentially affect the
test stability, controls should be assayed more
frequently.

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Objective of Quality Control

 high level of error detection

 low level of false rejections
 simplest control rules
 least number of controls.

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Understanding Quality control
In order to better understand quality control one must
become familiar with certain statistical terms,
concepts, and calculations.

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Basic Statistics
 Mean: sum of data
# of data points
e.g. Calcium levels: mg/dl
1. 9.2
2. 9.3
3. 9.1
4. 9.2
5. 9.3
6. 9.9

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Basic Statistics Cont’
Mean & SD

Mean = 9.2 + 9.3 + 9.1+ 9.2 + 9.3 + 9.9

6
= 9.2

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Standard Deviation

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Basic Statistics Cont’
SD
SD for calcium levels:
√ (9.2 – 9.2) 2 + (9.3 – 9.2)2 + ….
6 -1
= 0.2 mg/dl
SD can compare a set of data measured in the
same units.
The SD often increases as the concentration
increases, therefore it is often useful to express the
SD as a percentage of the mean concentration.

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Basic Statistics Cont’
SD
SD: Most laboratories use the acceptable parameter of
a 2 SD range, which means that 5 % of values will fall
outside this range

68 % of the values is included between +1 SD & -1 SD

95.5 % lie between +2 SD & -2 SD
99.7 % lie between +3 SD & -3 SD

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Normal Distribution

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Basic Statistics Cont’
SD

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Basic Statistics Cont’
Accuracy (Bias)

The degree that a measurement deviates from the true

(or absolute) value.

This is determined by comparing the mean of

repeated testing values with the true value determined
by a reference method.

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Bias

Bias = Target value – Laboratory Mean

% Bias = Laboratory Mean- Target value x 100

Target value

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Precision
Precision tests the reproducibility of an assay method.

It measures how closely replicate test results on a

given sample agree with each other.

Precision is usually expressed in terms of standard

deviation, and can be calculated for any procedure

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Accuracy & Precision

The mean is related to accuracy or systematic

error.
The standard deviation is related to precision or
random error.
The bigger the SD, the wider the distribution, the
greater the random error, and the poorer the
precision of the method.
Can I get precise results without accuracy?

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Accuracy and Precision

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Basic Statistics
Coefficient of Variation (CV)
Can compare variability between different units or
different populations: Kg,m ; male, female
Because the CV reflects a ratio of the SD to the
concentration, it often provides a better estimate
of method performance over a range of
concentration
= SD * 100
mean
CV (calcium levels) = 0.2 mg/dl * 100
9.2 mg/dl
= 2.17
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Coefficient of Variation (CV)
The smaller the CV,
the more the values tend to cluster around the mean
and the more reproducible or reliable is the result

e.g.:
Cholesterol levels
Set A (10 values): Mean: 145, SD: 10
Set B (10 values): Mean: 80, SD: 10

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Coefficient of Variation (CV)

Set A: CV = 10 * 100 = 6.9

145
Set B: CV = 10 * 100 = 12.5
80
Which set is more reproducible?

Therefore, one advantage of calculating the CV is that

one can use the results to compare two assay methods
that have very different mean values.

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Types of Analytical Errors

Systemati
c Errors

Random
Errors

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Random Error

Random error, or imprecision is described as an

error who’s direction and exact magnitude cannot
be predicted.

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Systematic Errors
Systematic error, or inaccuracy is
an error that is always in one
direction.

Systematic errors cause all the test

results to be either high or low.

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Causes of Systematic Errors
A. change in reagent or calibrator lot
B. wrong calibrator values
C. improperly prepared reagents
D. deterioration of reagents, calibrators, or
photometric light source
E. inadequate storage of reagents or calibrators
F. change in sample or reagent volumes due to
pipette maladjustments
G. change in temperature of incubators and
reaction blocks
H. change in procedure from one operator to
another.

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Inaccuracy: Trend & Shift
Control results should be distributed on both sides of the
mean value.

Inaccuracy occurs when the mean for the control material

is changing and is reflected by either a trend or shift in
control values.

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Trend
A trend is said to occur when there is a consistent
decrease or increase in control values.

A trend indicates a gradual loss of reliability in the

test system.

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Trend
Trends may be caused by:
 Deterioration of the instrument light source
 Gradual accumulation of debris in sample/reagent
tubing
 Gradual accumulation of debris on electrode surfaces
 Aging of reagents
 Gradual deterioration of control or calibration
materials
 Gradual deterioration of incubation chamber
temperature
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Shift
A shift is found when 5 successive values fall above
or below the mean.

It is a change of the mean for the control material.

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Shift
Shifts may be caused by:
 Sudden failure or change in the light source
 Change of reagent lot
 Major instrument maintenance
 Sudden change in incubation temperature
 Change in room temperature or humidity
 Failure in the sampling system
 Failure in reagent dispense system
 Inaccurate calibration/recalibration

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Perfect control

No trends
No shifts

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Shift

Trend

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Proficiency Testing
(EQC)

Laboratories participating in a proficiency testing

program receive a set of “unknown” liquid or
lyophilized samples.
The samples are assayed by the laboratory for each test
performed.
Results are obtained and reported to the proficiency
agency.

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Proficiency Testing Cont’

The agency collects the data and, using various

statistical models, determines what the consensus
value of the unknown sample should be for each test.

The test result reported by each laboratory is

compared to this consensus value and the laboratory is
graded for accuracy.

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Proficiency Testing Cont’
The proficiency agency provides a summary
report that contains summary data of all the
participating laboratories along with an accuracy
grading report.

The summary report identifies, among other statistics,

the standard deviation of all values submitted by
participating laboratories for each test.

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EQC normal distribution charts

More often, EQAS (External Quality Assurance

scheme) coordinators represent graphically the total
performance of all the laboratories in a normal
distribution chart.

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EQC normal distribution charts

The normal distribution chart consists of bars

(histogram) which correspond to certain groups of
values.

The bars may have different colors depending on the

distance from the consensus mean.

The bar that corresponds to each laboratory’s result is

marked by various methods

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EQC Histogram

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 How do proficiency testing schemes evaluate the accuracy of individual laboratories?

Most schemes convert the participant’s result into a

‘z-score’ (SDI)
This score reflects the actual accuracy achieved (i.e.,
the difference between the participant’s result and the
accepted true value.

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Z- Score
Measures your Lab accuracy in comparison with the
other participating Labs
Z score = xi – μ
s

Where: xi = Single value (your value)

μ = Mean value
s = Standard deviation

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How should z-scores be interpreted?

A score of zero implies a perfect result.

Laboratories complying with the PT scheme will

commonly produce scores falling between - 2 and 2
A score outside the range from –3 to 3 would be very
unusual

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Standard Deviation Index [SDI]

The standard deviation index [SDI] is a peer-based

estimate of reliability.
If the peer group mean is defined as xGroup , the
standard deviation is defined as sGroup and the
laboratory’s mean is defined as xLab.

SDI = (xLab - xGroup)/sGroup

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SDI acceptance criteria
The target SDI is 0.0 which indicates a perfect
comparison with the peer group.
The following guidelines may be used with SDI:
•• 1.25 or less is considered acceptable.
•• 1.25 – 1.49 is considered acceptable to marginal
performance.
•• 1.5 – 1.99 is considered marginal performance
•• 2.0 or greater is generally considered to be
unacceptable performance

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WHY Proficiency Testing???
 Help evaluate existing test methods by comparison to
other peer labs.
 Help to assure accurate test analysis under laboratory
operating conditions.
 Help complement test kit acceptance criteria
 Provide added confidence
 Comply with regulatory guidelines
 Test competency of personnel who are performing the
analysis.

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List of International Proficiency Agencies (in our Lab)

1. BIO-RAD: External Quality Assurance Service (EQAS),

Immunoassay Monthly Program (BC70/BC75/BC7L)
2. BIO-RAD: External Quality Assurance Service (EQAS),
Clinical Chemistry Monthly Program (BC50/BC5L)
3. Qualiris by Stago: External Quality Assessment Program
4. Euroimmun, Institute of Quality Assurance
5. Randox Laboratories: RIQAS, HbA1C
6. REQAS WHO / EMRO: Bacteriology, Parasitology,
Virology & Mycology
7. Hematology
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Interlaboratory QC Programs

In an interlaboratory comparison program,

laboratories submit monthly data collected for each
control product tested.
e.g.: Hematology: Interlaboratory Quality Assurance
Program

Provides statistics collected from repeated daily testing.

These data are combined with data from other

laboratories which use the same instrument.
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Allowable Total Error
The mathematical definition of the total analytical
error (TE) is:
Total analytical error =
Random Error (RE) + Systematic Error (SE)

Under ideal circumstances, total analytical error equals

to zero, but this cannot be achieved in daily practice.

Only SE can be zero (SE ≥ 0) where as RE is always

greater than zero (RE > 0) because of the existence of
the inherent error.
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Allowable Total Error Cont’
Since TE > 0 is unavoidable, TE of every single
determination must be lower than a specified limit.

This limit is called “allowable total analytical error”

(aTE) and it is different for each analyte being
determined in a clinical laboratory.

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Allowable Total Error Cont’
Allowable Total Error (TEa): states the laboratory’s policy for
how much error is medically acceptable. Regulatory
requirement (e.g. CLIA’88) represent an upper limit.
e.g.: SGPT : ± 20%
Amylase: ± 30%
Calcium: ± 1.0 mg/dL 
Hemoglobin: ± 7%
Platelets: ± 25%
WBC: ± 15%

 
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CLIA TEa: old and new (2024)
New Old

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How to measure Sigma for analytes

Sigma-metric = (TEa– Bias)/CV

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Sten Westgard

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Westgard QC Rules
First, a non-technical description.
When my daughter Kristin was young and living at
home, she liked to party.
One day when she told me she was again intending to
be out late, I felt the need to exert some parental
control over her hours.
So I told her that if she was out once after three,
twice after two, or four times after one, she was in
big trouble. That's multirule control.

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Westgard Multirule QC
Multirule QC uses a combination of decision criteria, or control
rules, to decide whether an analytical run is in-control or out-
of-control.

It is also useful in determining if the problem is random error

(addressed by rules R4s & 1_3s) or systematic error (addressed
by rules 2-2s & 10X)

The well-known Westgard multirule QC procedure uses 5

different control rules to judge the acceptability of an
analytical run.

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Westgard QC Rules Cont’
“Westgard rules” are generally used with 2 or 4 control
measurements per run.

This means they are appropriate when two different

control materials are measured 1 or 2 times per
material, which is the case in many chemistry
applications.

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Westgard QC Rules Cont’
Some alternative control rules are more suitable when
three control materials are analyzed.

Common for applications in hematology, coagulation,

and immunoassays.

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Westgard Rule: 10X

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Westgard rules applications
If one measurement is made on each of two different control materials in an
analytical run, control rules can be applied as follows:

The two control results "within a run" can be inspected by applying a 13s rule to
each material, as well as the 22s and R4s rules "across materials."
The 22s rule can also be applied to the last two measurements "within a
material and across runs."
The 41s rule can be applied to the two control measurements in the current
run and the two measurements in the previous run, i.e., the rule can be
applied "across materials and across runs".
The 41s rule can also be applied to the last four measurements "within a
material and across runs," which now requires the control results from the
three previous runs.
The 10x rule can be applied to both control measurement in a run for the last
five runs, or to the measurements on just one material for the last ten runs.

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Westgard Rules Cont’
Random (sudden, unpredictable)
 1-3S, R4-S

Systematic (over time)

 2-2S, 4-1S and 10-x
 Shift
 Trend

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Every lab result might include an error.

Our job is to limit that error to a tolerable amount that is not clinically
significant for patient management.

Strict adherence to good laboratory practices:

including specimen collection,
calibration procedures,
and proper internal quality control
will certainly provide doctors the best clinical decisions to
achieve patient welfare.

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Quality is everyone’s job
If it’s not documented, it’s not done
Say what you do; do what you say (Walk the Talk)
Quality first, production second
Inaccurate results are never timely
Do things right the first time

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References
Greg Cooper, Basic Lessons in Laboratory Quality
Control, Bio-Rad Laboratories, 2008.
Petros karkalousos and Angelos Evangelopoulos,
Quality Control in Clinical Laboratories, 2011.
www.westgard.com
Roche Diagnostics

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