Quality Assessment

Lecture 2
Laboratory Analysis

The goal of laboratory

analysis is to provide the
reliable laboratory data to the
health-care provider in order
to assist in clinical decision-
making.
 Modern medicine relies on the provision of accurate
analytical results from the laboratory both to confirm
diagnoses and to monitor therapy.
 If laboratory results are to play a proper role in diagnoses
and treatment then they must be trustworthy
 Experience has shown that all analytical results are
subject to errors arising from a variety of causes
 It is essential that these errors be kept to a minimum.
 QA in Laboratories
 The assurance of high-quality laboratory results relies on a
commitment to all aspects of the testing system, including
attention to:
 preanalytical,
 analytical,
 and postanalytical factors.
1. Preanalytical factors are those factors that affect the laboratory
results due to handling of the specimen sample prior to analysis.
2. The analytical phase includes verification of instrument linearity,
precision, accuracy, and overall reliability through the use of
standard materials, quality control (QC) samples, procedures,
and QC rules.
3. Postanalytical factors include timely and accurate laboratory result
reporting and other aspects that occur after the analysis phase.
 WHO Definition

 Quality assurance has been defined by WHO as:

 The total process whereby the quality of the laboratory reports can
be guaranteed. It has been summarized as the:
 Right result, at the
 Right time, on the
 Right specimen, from the
 Right patient, with the result interpretation based on,
 Correct reference data, and at the
 Right price.
Quality Assessment
 Quality assessment or quality assurance (QA)
is a complete system of creating and
following procedures and policies to aim for
providing the most reliable patient laboratory
results and to minimize errors in the
preanalytical, analytical, and postanalytical
phases.
Sources Of Error
 Erroneous results are at best a nuisance; at worst, they have
potential for causing considerable harm.
 Errors can be minimized by careful adherence to robust, agreed
protocols at every stage of the testing process: this means a lot
more than ensuring that the analysis is performed correctly.
 Errors can occur at various stages in the process:
 pre-analytical, occurring outside the laboratory,
 analytical, occurring within the laboratory,
 post-analytical, whereby a correct result is generated but is
incorrectly recorded in the patient's record,
Preanalytical errors

PROCESS POTENTIAL ERRORS

Test ordering inappropriate test
Handwriting not legible
Wrong patients ID
Special requirements not specified
Specimen acquisition
Incorrect tube or container
Incorrect patient ID
Inadequate volume
Invalid specimen (hemolysed or diluted)
Collected at wrong time
Improper transport conditions
Analytical errors

Analytical Instrument not calibrated

Measurement correctly

Specimens mix – up
Incorrect volume of specimen
Interfering substances present
Instrument precision problem
Post Analytical errors

Test interpretation
Previous values not available for
comparison

Test reporting Wrong patient ID

Report not legible
Report delayed
Transcription error
 Overview of Preanalytical Variables

 Preanalytical refers to everything creating an impact on the patient

specimen before it is tested for the analyte.
 Many things can go wrong with the specimen while it is collected
from the patient and sent to the laboratory for testing.
 If the patient and the specimen aren’t correctly identified,
 the specimen isn’t collected or handled properly,
 Then, the specimen won’t be worthy of testing.
 Suitable transport conditions
 such as in ice water

 or with protection from light

 may be necessary in order to preserve certain

analytes in the specimen prior to testing.
Preanalytical Variables

 Specimen collection and handling

 Hemolysis
 Specimen Contamination
 Specimen Transport
 Additives to Blood
 Specimen collection and handling

 A test result is no better than the quality of the specimen received in

the laboratory.
 Specimen collection and handling procedures must be explained to
all parties involved in the processing of specimens ( nursing
personnel, physician assistants, and health-care professionals)
 Laboratory personnel are responsible for
 minimizing preanalytical errors based on acceptance or rejection
of the received specimens.
 for training other personnel involved in specimen collection and
transport and for communicating effectively in order to maintain
optimal quality of specimens for laboratory testing.
 Since preanalytical errors seem to make up the majority of most
laboratory test problems, proper training is an important area to
address.
Hemolysis
 Hemolysis is generally a preanalytical problem that can be
avoided.
 It is graded based on visible presence of hemoglobin, when
greater than 20 mg/dL, and it is often graded as mild, moderate,
or gross hemolysis.
 Gross hemolysis will often impact on almost every test method
due to
 release of intracellular constituents into the serum
(potassium, phosphates, LDH, and AST)
 and colorimetric interference due to pigments.
 Grossly hemolyzed specimens should always be rejected.
 Specimen Contamination
 The type of blood specimen contamination resulting from IV fluids
would vary with the type of fluid being infused.
 A dextrose solution (sugar) IV infusion would yield
 extremely high glucose results in venous specimens collected
above or near the infusion area.
 Total parenteral nutrition (TPN) fluid contains most of the
required daily nutrients for a person who can’t ingest food.
 TPN fluid contamination in a specimen creates gross turbidity
along with elevated lipid and glucose values and potassium levels
too high to be compatible with life.
 In specimens from a patient receiving a saline IV infusion,
 potassium and protein results may be nearly one-third lower than in
specimens not contaminated with saline IV solution.
 Sodium and chloride results will be falsely elevated due to
contamination from saline IV fluid.
Specimen Transport
 Many chemical compounds are stable within plasma or serum in
vitro for only a short time.
 Levels of potassium, ammonia, lactate, bilirubin, glucose, CO2 ,
sodium, urea, and alkaline phosphatase, for example, are
particularly affected by contact with blood cells, which can
continue to undergo cellular metabolic processes after blood
has been removed from the body.
 E.g. Glucose will decrease as much as 12% per hour if not
separated from blood cells or preserved.
Specimen Transport
Additives to Blood

 Using the wrong additives or the wrong amount of

additive can cause adverse effects on blood
specimens.
 sodium oxalate, sodium fluoride, or sodium heparin cannot
be used for samples needed for sodium analysis
 because they increase the level of sodium.
 Ammonium heparin should not be used for specimens
intended for plasma ammonia or urea testing
 because it adds to the chemical being measured.
 Sodium fluoride cannot be used for enzyme analysis
samples
 because fluoride acts as an inhibitor to most enzyme activity.
 Ethylenediaminetetra-acetic acid (EDTA), sodium citrate,
and sodium oxalate cannot be used in samples that will be
used for mineral analysis
 because they remove calcium and magnesium.
Sample Preparation
 Sample preparation involves processing of the
sample prior to and in preparation for analysis.
 Processing involves centrifugation,
 and making an aliquot of the specimen in a test tube
or sample cup
 Keep in mind that clotted or whole blood cells can
affect chemicals in the sample over a period of time,
such that additional chemicals arise or some
chemicals are consumed
How To Control Preanalytical Errors

 It is very difficult 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 Identification
 The highest frequency of errors occurs with the use of
handwritten labels and request forms. The use of bar code
technology has significantly reduced ID problems.
How To Control Preanalytical Errors

 training of personnel for proper collecting and

handling of samples, including adherence to
specific steps and maintaining turnaround time
involving sample receiving and accessioning.
 Use of well-written procedures and policies can
help to minimize preanalytical errors (specimen
collection manual)
 Analytical variables and Quality Control

 The ideal analytical method is accurate, precise, sensitive and

specific.
 Accurate: It gives a correct result
 Precise: that is the same if repeated
 Sensitive: It measures low concentrations of the analyte
 Specific: is not subject to interference by other substances
 In addition, it should preferably be cheap, simple and quick to
perform.
 Laboratory staff make considerable efforts to achieve this and
analytical methods are subject to rigorous quality control.
 Control of analytical variables

 There are many analytical variables that must

be carefully controlled:

 Water quality
 Calibration of analytical balances
 Calibration of volumetric glassware and pipettes
 Stability of electrical power
 Stability of temperature of heating baths,
refrigerators, freezers and centrifuges
 Standard operating procedures

 These are also referred to as laboratory bench

manual
 Important features of SOP’s
 Applicable and available in the laboratory where they
will be used
 Clearly written and easy to understand and follow
 Kept up to date using appropriate technologies
 The Standard operating Procedure

 The Standard operating Procedure should contain the

following:

 Procedure name
 Clinical significance
 Principle of method
 Specimen of choice
 Reagents and equipments
 Procedure
 Reference values
 Comments
 References
Method Validation
 Method validation should be performed
before a test procedure is placed into routine
use.
 Validation may be accomplished by
thoroughly testing reference materials or by
comparison of results of tests performed by
an alternative method.
Method Validation

 Method validation should provide evidence of

the following:
 Accuracy
 Precision
 Sensitivity
 Specificity
 Linearity
Accuracy & Precision

 Accuracy
- the closeness of the estimated value to the true mean
- can be checked by the use of reference materials
which have been assayed by independent methods of
known precision

 Precision
- reproducibility of a results, whether accurate or
inaccurate within a define frame time ( eg: within the
same day, from week to week etc )
- can be controlled by replicate tests, check tests on
previously measured specimens and statistical
evaluation of results
Good Accuracy Good Neither Good
Good Precision Precision precision Nor
Only Accuracy
 Accuracy: both are
equally precise, but in
method D the mean value
differs from the true value.
 The mean for method C is
equal to the true value.
 Both methods are equally
precise, but method C is
more accurate.
 The graph shows the
distribution of results for
repeated analysis of the
same sample by different
methods.
 Precision: the mean value
is the same in each case,
but the scatter about the
mean is less in method A
than in method B.
 Method A is, therefore,
more precise.
 Specificity
 The specificity of a test is a measure of the
incidence of negative results in persons known
to be free of a disease, that is 'true negative'
(TN).
 A specificity of 90% implies that 10% of disease-
free people would be classified as having the
disease on the basis of the test result:
 they would have a 'false positive' (FP) result.
Sensitivity
 Sensitivity is a measure of the incidence of
positive results in patients known to have a
condition, that is 'true positive' (TP).
 A sensitivity of 90% implies that only 90% of
people known to have the disease would be
diagnosed as having it on the basis of that
test alone:
 10% would be 'false negatives' (FN).
Calculations
 Specificity and sensitivity are calculated as
follows:
Specificity
 Ability to correctly identify individuals without disease

 1000 people tested

 875 positive tests (275 false positive)
 125 negative tests (25 false negative)

 TN /(TN + FP)
 Specificity = 100/(100+275) = .27 or 27%
Sensitivity
 Ability to correctly identify individuals with disease

 1000 people tested

 875 positive tests (275 false positive)
 125 negative tests (25 false negative)

 TP/(TP + FN) – may be expressed as a percent

 Sensitivity = 600/600 +25 = .96 (96%)
High Specificity desired when

 Disease is serious but is not treatable or

curable
 Knowledge that disease is absent has
physiological or public health value
 False-positive results can lead to serious
psychological or economic trauma
High Sensitivity desired when

 Disease is serious and should not be missed

 Disease is treatable
 False positives do not lead to serious
psychological or emotional trauma
Ideal Test
 An ideal diagnostic test would be:
 100% sensitive,
 giving positive results in all diseased subjects,

 and also 100% specific,

 giving negative results in all subjects free of disease.

 Individual tests do not achieve such high standards.

 Factors that increase the specificity of a test tend to
decrease the sensitivity and vice versa.
 If it were decided to diagnose thyrotoxicosis only if the plasma
free thyroxine concentration were at least 32 pmol/L (the upper
limit of the reference range is 26 pmol/L),
 the test would have 100% specificity; positive results
(greater than 32 pmol/L) would only be seen in
thyrotoxicosis.
 On the other hand, the test would have a low sensitivity in
that many patients with mild thyrotoxicosis would be
misdiagnosed.
 If a concentration of 20 pmol/L were used,
 the test would be very sensitive (all those with thyrotoxicosis
would be correctly assigned) but have low specificity,
 because many normal people would also be diagnosed as
having thyrotoxicosis.
Quality Control Programs
 The goal of a well-defined QC system is to detect
immediate errors in an analytical run while minimizing the
number of false rejections.
 The simplest type of QC procedure uses one rule to reject
the analysis based on QC results falling outside of a range
such as the 95% range.
 These facts are based on probability that the correct
decision was made 95% of the time when results that fall
within this range are accepted.
 When testing is qualitative—that is, positive or negative—
a simple one-rule policy is acceptable.
What is Quality Control?
 Quality Control in the clinical laboratory is a
system designed to increase the probability
that each result reported by the laboratory is
valid and can be used with confidence by the
physician making a diagnostic or therapeutic
decision.
 Control Of The Analytical Quality Using Stable
Control Materials

 The performance of analytical methods can be monitored by

analyzing specimens whose concentrations are known and then by
comparing the observed values with known values.
 The known values are usually represented by an interval of
acceptable values, or upper and lower limits for control (control limits)
 When the observed values fall within the control limits – analysis is
working properly
 When the observed value fall outside the control limits the analyst
should be alerted to the possibility of problems in the analysis.
 QA includes analyzing known samples called quality
control (QC) samples along with unknown (patient)
samples to test for analytical problems.
 When QC samples do not produce accurate and
precise results, it can be assumed that any patient
results obtained at the same time are also erroneous.
 Following a set of guidelines for acceptance or
rejection of patient results based on the QC results
helps to assure reliability of the analysis.
Standards and Controls
 Standard
 A substance that has an exact known value

and that, when accurately measured, can

produce a solution of an exact concentration
 Not usually used on a daily basis

 Used to calibrate new instruments, recalibrate

instruments after repair, at manufacturer’s

recommended intervals, or if a method is out
of control
Control
 A solution that contains the same constituents as
those being analyzed in the patient sample
 Most are commercially produced from pooled sera
 The manufacturer has analyzed each lot of serum for
a variety of test components and the expected range
of assay values for each component is provided to
the laboratory when shipped
Control
 Controls are analyzed with each patient test
or batch of tests and the results are
compared with the manufacturer’s range of
values
 For most tests, a “normal” control and an
“abnormal” control are analyzed with each
patient test or batch of tests
 Results are plotted on a QC record called a
Levey-Jennings Chart
Quality control (QC) procedures
 Quality control (QC) procedures function by detecting
analytical errors;
 ideally any error large enough to invalidate the medical
usefulness of laboratory results should be detected.
 The measurement of QC samples will detect
problems of precision and accuracy over time.
 Interpretation of control results is based on using
specific rules for acceptance and rejection of QC
results, documenting results and decisions, and
having a process for resolving problems that result in
rejection of results.