QUALITYCONTROL

Mobeen Tariq khan

(Supervisor Lab ANTH)
 DEFINITIONS
Quality Control - QC refers to the measuresthat must be
include
d during each assay run to verify that the test is working properly.

Quality Assurance - QA is def ined as the overall program that

ensures that the f inal results reported by the laboratory are correct.
“The aim of quality control is simply to ensure that the results
generated by the test are correct. However, quality assurance is
concerned with much more: that the right test is carried out on the
right specimen, and that the right result and right interpretation is
delivered to the right person at the right time”
IMPORTANT TERMINOLOGIES
Quality
The Degree to which a set of
inherent characters fulf ils the
requirements.
Precision
Precision is the reproducibility of an analytical
method

Accuracy
Accuracy def ines how close the measured value is to the actual
Sensitivity
Sensitivity of an assay in a measure of how little of the analyte
the method can detect.

Specif icity
Specif icity of a assay related to how good the assay is at
discriminating between the requested analyte and potentially
interfering substances.
Standard
This is a substance of constant composition of suff icient purity to
be used for comparison purposes or standardisation
Control
This is a sample, which is chemically and
Physically similar to
unknown specimen
A solution , lyophilised preparation or pool of
collected human or
animal specimen or artif icially derived material intend for use in
the QC process.
Calibrator:
A material or
solution of known
concentration (or activity /
intensity) used
to
calibrate or adjust a
measurement procedure. It
is also used to
calculate the
concentration of an
unknown sample (as
standard)
 Quality Control
Variation in results

Biochemical measurements vary for two reasons,

namely:
analytical variation
biological variation.
 ANALYTICAL
ERRORS
Analytical Measurement
Instrument not calibrated
correctly
Specimens mix – up
Incorrect volume of specimen
Interfering substances present
Instrument precision problem

Test reporting
Wrong patient ID
Transcription error
Report not legible
Report delayed
 POSTANALYTICALERRORS
Test interpretation
Interfering substance not
recognized
 Specif icity of the test not
understood
Precision limitation not recognized
Analytical sensitivity not
appropriate
 Previous values not available for
comparison
HOWTOCONTROLTHESEERRORS?
PRE ANALYTICAL VARIABLES
It is very diff icult to establish effective methods for monitoring and
controlling preanalytical variables because many of the variables are
outside the laboratory areas.
Requires the coordinated effort of many individuals and hospital
departments
Patient Identif ication
The highest frequency of errors occurs with the use of handwritten
labels and request forms. The use of bar code technology has
signif icantly reduced ID problems.
Turn around time
Delayed and lost test requisitions, specimens and reports can be
major problems for labs. Recording of the actual times of specimen
collection, receipt in the lab and reporting of results with use of
computers will solve these problems.
Transcription error
A substantial risk of transcription error exists from manual entry of data
even with the double checking of results, computerization will reduce
this type of transcription error.

Patient preparation

Lab tests are affected by many factors, such as, recent intake of food,
alcohol, or drugs
smoking
exercise
stress
sleep
posture during specimen collection
The lab must def ine the instructions and procedures compliance with
these instructions can be monitored directly efforts should be made to
correct non compliance
GENERALPRINCIPLESOFCONTROLCHARTS

 Control charts are simple graphical displays in which the

observed values are plotted versus the time when the
observations are made.

 The control limits are calculated from the mean (x) and
standard deviations (s)
Internal Quality Control Programfor
Serological Testing
An internal quality control program depend on the use of internal
quality control (IQC) specimens, Shewhart Control Charts, and the
use of statistical methods for interpretation.

Internal Quality Control Specimens

IQC specimens comprises either (1) in-house patient sera (single

or pooled clinical samples), or (2) international serum standards
with values within each clinically signif icant ranges.
QC Log with Patient Results
 Basic statistics to develop an acceptable
control range
The most fundamental statistics used by the laboratory are the mean [x]
and standard deviation [s].
Calculating a Mean [x]:
The mean (or average) is the laboratory’s best estimate of the analyte’s
true value for a specif ic level of control.
Calculating a Standard Deviation [s]:
 Standard deviation is a statistic that quantif ies how close numerical
values (i.e., QC values) are in relation to each other
 Standard deviation is calculated for control products from the same
data used to calculate the mean.
 It provides the laboratory an estimate
of test
consistency
at specif ic
concentrations.
Mean [x] Standard Deviation
[s]
 Creating a Levey-Jennings Chart
• Standard deviation is commonly used for preparing Levey-Jennings (L-J or
LJ) charts.
The Levey-Jennings chart is used to
graph successive
(run-to-run or
quality control values.
• A chart is created for each test and level of control.
• The f irst step is to calculate decision limits. These limits are ±1s, ±2s and ±3s
from the mean.
• From the mean and standard deviation value calculated in the previous slide
we can now construct the Levy Jennings chart as follows:
The Levey-Jennings chart that was developed can be overlaid onto a bell-shaped curve to
illustrate the
overall distribution of quality control values
Cont..
• When an analytical process is within control, approximately 68%
of all QC values fall within ±1 standard deviation (1s).
• Likewise 95.5% of all QC values fall within ±2 standard
deviations (2s) of the mean. About 4.5% of all data will be
outside the ±2s limits when the analytical process is in control.
Approximately 99.7% of all QC values are found to be within ±3
standard deviations (3s) of the mean.
• As only 0.3%, or 3 out of 1000 points, will fall outside the ±3s
limits, any value outside of ±3s is considered to be associated
with a signif icant error condition and patient results should not
be reported.
 Systematic Errors
Systematic error is evidenced by a change in the mean of the control values. The change in the mean may be
gradual and demonstrated as a trend in control values or it may be abrupt and demonstrated as a shift in
control values.
Trends: A trend indicates a gradual loss of reliability in the test system. Trends are usually subtle.
Causes of trending may include:

 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 materials
 Gradual deterioration of incubation chamber
 temperature (enzymes only)
 Gradual deterioration of light f ilter integrity
 Gradual deterioration of calibration
Shif
t
Abrupt changes in the control mean are def in ed as shifts. Shifts in QC data
represent a sudden and dramatic positive or negative change in test system
performance. Shifts may be caused by:
 Sudden failure or change in the light source
 Change in reagent formulation
 Change of reagent lot
 Major instrument maintenance
 Sudden change in incubation temperature (enzymes only)
 Change in room temperature or humidity
 Failure in the sampling system
 Failure in reagent dispense system
 Inaccurate calibration/recalibration
 Random Errors

 Random error is any deviation away from an expected

result.
 For QC results, any positive or negative deviation away
from the calculated mean is def ined as random error.
 There is acceptable (or expected) random error as
def ined and quantif ied by standard deviation.
 There is unacceptable (unexpected) random error that
is any data point outside the expected population of
data (e.g., a data point outside the ±3s limits).
 Westgard Rules

There are six basic rules in the Westgard scheme.

These rules are used individually or in combination to evaluate the
quality of analytical runs.
Most of the quality control rules can be expressed as NL where
Nrepresents the number of control observations
to be evaluated and
L represents
Thus 1 the statistical
represents a control limit
rule for evaluating
that is thewhen
violated control
one contro
observations
3s
l observation exceeds the ±3s control limits.
Rule 12s Rule 13s
This rule merely warns that random This rule identif ies
error or systematic error may be
present in the test system unacceptable random error
The relationship between this value and or possibly the beginning of a
other control results within the current large systematic error. Any
and previous analytical runs must be QC result outside ±3s
examined. If no relationship can be violates this rule.
found and no source of error can be
identif ied, it must be assumed that a
single control value outside the ±2s
limits is an acceptable random error.
Rule 22s
This rule identif ies systematic error only. The criteria for violation of
this rule are:
• Two consecutive QC results
• Greater than 2s
• On the same side of the mean

There are two applications to this rule: within-run and across runs.
The within-run application affects all control results obtained for the
current analytical run.
•If a normal (Level I) and abnormal (Level II) control are assayed in
this run and both levels of control are greater than 2s on the same
side of the mean, this run violates the within-run application for
systematic error. If however, Level I is -1s and Level II is +2.5s (a
violation of the 12s rule), the Level II result from the previous run
must be examined. If Level II in the previous run was at +2.0s or
greater, then the across run application for systematic error is
violated.
Violation of the within-run application indicates that systematic
error is
present and that it affects potentially the entire analytical curve.
Violation of the across run application indicates that only a single
portion of the analytical curve is affected by the error.
 Rule R4s

• This rule identif ies random error only,

and is applied only within the current
run. If there is at least a 4s difference
between control values within a
single run, the rule is violated for
random error.
• For example, assume both Level I
and Level II have been assayed
within the current run. Level I is
+2.8s above the mean and Level II is
-1.3s below the mean. The total
difference between the two control
levels is greater than 4s (e.g. [+2.8s
– (-1.3s)] = 4.1s).
Rule 31s
The criteria which must be met to violate this rule
are:
• Three consecutive results
• Greater than 1s
• On the same side of the mean

Rule 41s

The criteria which must be met to violate this rule

are:
• Four consecutive results
• Greater than 1s
• On the same side of the mean

There are two applications to the 31s and 41s rule. These are within control material (e.g. all
Level I control results) or across control materials (e.g., Level I, II, and III control results in
combination).

Within control material violations indicate systematic bias in a single area of the method curve
while violation of the across control materials application indicates systematic error over a
broader concentration
 Rules 7X 8X 9X
10X12X

These rules are violated when there are: 7

or 8, or 9, or 10, or 12 control results On
the same side of the mean regardless of
the specif ic standard deviation in which
they are located.

Ea ch of t h e se rule s a lso ha s tw o
applications: within control material (e.g.,
all Level I control results) or across control
materials (e.g. Level I, II, and III control
results in combination).

Within control material violations indicate

systematic bias in a single area of the
me thod curve w hile violation of the
across control materials application
indicates systematic bias over a broader
concentration
 Coeff icient of Variation [CV]
• The Coeff icient of Variation [CV] is the ratio of the standard deviation to the mean and is
expressed as a
percentage.
• CV allows the technologist to make easier comparisons of the overall precision.
• Standard deviation typically increases as the concentration of the analyte increases, the CV can be
regarded as a statistical equalizer.
• Technologist/technician who is comparing precision for two different methods and uses only
standard deviation, can be easily misled
• For example, a comparison between hexokinase and glucose oxidase (two methods for assaying
glucose) is required. The standard deviation for the hexokinase method is 4.8 and it is 4.0 for glucose
oxidase. If the comparison only uses standard deviation, it can be incorrectly assumed that the
glucose oxidase method is more precise that the hexokinase method. If, however, a CV is calculated,
it might show that both methods are equally precise. Assume the mean for the hexokinase
method is 120 and the glucose oxidase mean is
100. The CV then, for both methods, is 4%. They are equally precise.
 Coeff icient of Variation Ratio[CVR]
• Accuracy of test results is paramount in
the clinical
laboratory,
precision
is just as
important
• One way a laboratory can determine whether the precision of a specif ic test is
acceptable is to compare its precision to that of another laboratory performing the
same test on the same instrument using the same reagents (laboratory peer group)
• If the CV for potassium on a particular instrument is 4% and the potassium for all
other laboratories using the same instrument is 4.2%, then the coeff ic ient of
variation ratio [CVR] is 4/4.2 or 0.95.
• Any ratio less than 1.0 indicates that precision is better than the peer group. Any
score greater than 1.0 indicates that imprecision is larger
• Ratios greater than 1.5 indicate a need to investigate the cause of imprecision
and any
ratio of 2.0 or greater usually indicates need for troubleshooting and corrective
action
 Standard Deviation Index [SDI]
• The standard deviation index [SDI] is a peer-based estimate of reliability. If the peer group
mean is
def ined as XGroup , the standard deviation is def ined as SGroup and the laboratory’s
mean is
defined as Xlab
• The target SDI is 0.0 which indicates a perfect comparison with the peer group. The
following guidelines may be used with SDI. A value of:
• 1.25 or less is considered acceptable.
• 1.25 – 1.49 is considered acceptable to marginal performance. Some investigation of
• the test system may be required.
• 1.5 – 1.99 is considered marginal performance and investigation of the test system is
• recommended.
• 2.0 or greater is generally considered to be unacceptable performance and remedial
action is usually required.
Thankyou!