Quality assurance &

Quality control

Quality Assurance (QA)

This describes all the steps taken both in and
outside the laboratory to achieve reliable results
starting with the preparation of the patient and
collection of specimen and ending with the
correct interpretation of results for the benefit of
patients.

Quality control (QC)

This describes all the steps taken by the
laboratory to ensure that tests are performed
correctly.
Quality control can be discussed in three parts
namely:-(1)Pre-analytical.
(2)Analytical.
(3)Post-analytical.

(A)Preanalytical phase
This includes the following steps:-(1)Selection of
appropriate test by the treating doctor.
(2)Preparation of a patient where this is
necessary for a particular test e.g. fasting blood
glucose.
(3)Correct collection, labelling , storage and
transport of specimens.
The laboratory should circulate written
instructions regarding:-

(i)Collection methods including advice on how to

avoid stasis when collection blood samples.
(ii)Types of container to use e.g. whether to use a
bottle or tube which contains an anticoagulant
,preservative or stabilizer.
The number of different containers should be
kept to a minimum.
(iii)Stability of different substances in samples
and the time within which a specimen should
reach the laboratory.
(iv)Special precautions which need to be taken for
certain specimens e.g. protecting blood
specimens against light and heat particularly

Its advisable however to protect all samples from

extremes of heat and light.
Many samples are best refrigerated at 2-8c until
analyzed or at least kept in a cool darker place.

(B)Analytical phase

This includes:-(1)Training laboratory workers to

perform tests correctly.
(2)Establishing performance standards for each
test method.
(3)Using of control samples and control chart.
(4)When ever possible taking part in external
quality assessment schemes.

(5)Making sure that equipment such as analytical

balances , colorimeters , water bath are being
used correctly and maintained adequately.

(C)Post analytical phase

(1)Reporting results clearly and with the
minimum of
delay.
(2)Correct interpretation of test results by the
treating
doctor.

Analytical errors in clinical

chemistry

Two types of error can occur when performing

clinical chemistry tests:-

(A)Errors of
scatter(Imprecision)

(B)Errors of
bias(inaccuracy)

(A)Errors of
Thesesscatter(Imprecision)
are irregular or random errors.

Results differ from the correct result by varying

amounts.
Causes of scatter (imprecision) in clinical
chemistry work:(1)Fautly technique including:Incorrect and variable pipetting.
Inadequate mixing of sample with reagents.
Incubations of tests at inconsistent temperatures
or for the incorrect length of time.
(2)Dirty tubes , pipettes or other items of

(3)Too heavy a workload resulting in fautly

techniques , mistakes being made or short cuts
being taken.
(4)Too low a workload resulting in loss of
concentration and errors being made.
(5)Fluctuating (erratic) colorimeter or
spectrophotmeter readings due to an unreliable
mains voltage supply.
(6)Use of dirty or finger marked cuvettes or
reading samples when they contain air bubbles.
(7)Incomplete removal of interfering substances
in serum e.g. red blood cells or proteins.

(B)Errors of bias (inaccuracy)

(systematic errors)
Theses are consistent or regular errors.
All results differ from the correct result by
approximately the same amount.
The commonest Causes of bias (inaccuracy)in
clinical chemistry work:(1)Use of unsatisfactory reagents because they
contain impure chemicals , have been prepared
wrongly , stored incorrectly , or used after stated
expiry date or known working life.

(2)Incorrect or infrequent calibration of a test

method.
(3)Use of control sera that has been wrongly
prepared , incorrectly stored or has expired.
(4)Tests being read at incorrect
wavelength(incorrect filter being used).

Quality control sera

Uses:-Are used to check for errors of bias(Errors

of reagents & Standard).
Two type:-(A)Locally prepared pooled control
sera.
(B)Commercially prepared.

Locally prepared Pooled

control
sera
Preparation and use of pooled sera
The use of a pooled control serum for the
routine daily control of tests is recommended
because such as serum can be prepared locally at
low cost.

Method of preparing a pooled serum

(1)At the end of a morning's or afternoon's work
collect any unused tested sera.
(2)Transfer those sera that have given normal
results to a screw-cap container , exclude from
the pool any sera which are not fresh or appear:Icteric(jaundiced).
Cloudy(lipaemic).
Pink coloured due to haemolysis.
Abnormally coloured due to dye.
When a control serum is prepared from a large
pool of human sera there is always the danger
that this pool may be positive for hepatitis

Every effort must be made therefore to exclude

from the pool any sera from patients with
hepatitis or with know history of the disease.
Before a pool serum is put into routine use a
sample must be tested for hepatitis antigens.
If found positive the serum must be discharged
in a safe manner.
(3)Freeze the pooled sera.
Continue to save and freeze the serum samples
until about 1 litre has been collected or sufficient
to last for 4-6 months.
(4)After sufficient sera has been collected allow
the frozen sera to thaw completely to room

Transfer all the sera to a large screw-cap bottle

and mix well but gently. Send a sample of the
pooled sera for hepatitis antigen testing.
(5)Add the following preservatives to the pooled
sera: 100mg sodium fluoride per 100ml of serum.
1ml of sodium borate merthiolate reagent per
100ml of serum.
(6)Mix well but gently.
(7)Check the glucose value. If necessary add an
appropriate amount of pure glucose to give a
concentration of about 6.7mmol/l.

(8)Centrifuge at medium speed (about 700g) for

about 30minutes to sediment any fibrin and other
debris.
Carefully remove the supernatant serum.
If lipid is present on the surface filter the serum
through glass wool or cotton gauze.
(9)Dispense the serum in about 1 ml amounts
into small container(Such as penicillin vials).
Immediately seal , label , and freeze at -20C or
below.
(10)For use remove one container ( or more if
required) of pooled serum and allow to thaw to
room temperature.

Important
Adequate mixing of the serum is essential
because separation occurs when serum is frozen
and thawed.
The serum should be used only on the day that
it thawed.
Any serum that is left at the end of the day
Use of
animal sera
should be thrown
away.
For most tests a perfectly satisfactory pooled
serum can be prepared form bovine or equine
serum.
Animal sera is hepatitis-free and therefore safer
to use than human sera.

Commercially prepared

Commercially prepared control sera are

available in two forms:-

(I)Freeze dried(Lyophilized)sera

When stored at 2-8C Unopened freeze-dried

sera can usually be kept for up to 2 years or
longer with out showing signs of deterioration.
An exact expiry date is usually printed on the
bottle label.
The length of time that a reconstituted control
serum can be kept when stored at 2-8C and
-20C is specified by the manufacture.
Substances such as bilirubin and some enzymes

When reconstituting a dried serum the following

precautions are necessary:(1)Read carefully the manufacturer's instructions.
Open the bottle slowly to avoid any loss of
material (the serum is often vacuum packed).
(2)Reconstitute with good quality glass-distilled
water or with the special diluent supplied by the
manufacture. Pipette accurately using a
chemically clean pipette.
(3)After adding the water or dilutent stopper the
container and gently swirl the contents.
Allow to stand for 10 minutes and then swirl
again.

Invert gently three or four times to ensure that

any remaining powder on the stopper will be
washed into the solution.
Stand for 2-3 minutes and then invert again
three or four times.
(4)Allow reconstituted serum to stand at room
temperature (20-28C) for the time specified by
the manufacturer ( usually 30-60 minutes).
After the waiting period gently remix the serum.

(5)Dispense the serum in 0.5-1ml amounts or as

required into small sterile containers.
To reduce the risk of contamination it is advisable
to transfer the serum by pouring not by pipetting.
(6)Label each container with the date and lot No.
(Batch No.) of the serum.
-Freeze immediately and store at -20C or below
until required.
For use allow the serum to warm to room
temperature. When completely thawed mix
gently but well.

2)Synthetically produced liquid sera

Most liquid synthetic control sera must be
stored at2-8C.
Unopened bottles can normally be kept for up to
about 1 year but when opened a liquid serum is
usually stable for only a few days.
If therefore a laboratory performs only a few
tests it should not buy this type of serum or buy it
only in small quantities.

Reference ranges

Laboratory staff and those requesting tests

should know the accepted reference ranges and
clinical significance of the results of the
quantitative tests performed in the laboratory.
This will ensure that significantly abnormal
results are detected, checked, reported, and
acted on as soon as possible.
Prompt action by laboratory staff may prevent
loss of life or lead to an earlier treatment with
more rapid recovery for a patient.
Test results are affected both by biological and
laboratory
factors and these need to be considered when

Biological factors
The following are among the biological factors
that contribute to differences in test results
among healthy people:(1)Age:-e.g. higher plasma urea concentrations
are found in the elderly.
Alkaline phosphatase activity is higher in growing
children compared with adults. Reference values
from neonates are very different from those of
adults.
(2)Gender:-e.g. higher values of haemoglobin,
plasma creatinine, urate, and urea are found
inmen compared with women during the

(3)Diet and nutritional state:-e.g. plasma

cholesterol and calcium are affected by diet.
(4)Time of the day (diurnal variation):-e.g. serum
iron levels rise as the day progresses.
(5)Posture:- e.g. plasma protein levels are lower
in samples collected from patients when they are
lying down.
(6)Muscular activity:-e.g. the concentration of
plasma creatinine rises following exercise.
(7)Dehydration:- e.g. haemoglobin, PCV,
whiteblood cells increase due to decrease in
plasma volume.

Reference ranges are also affected by weight,

phase of menstrual cycle, emotional state,
geographical location, rural or city life, climate,
genetic factors, cultural habits, smoking, andal
homeostatic variation.
Some reference values are also altered during
during pregnancy, e.g. haemoglobin and PCV
values decrease and neutrophil numbers
increase. Analytical factors
Among the analytical factors that influence
reference
ranges the most significant are:(1)Type of sample:-e.g. the concentration of
glucose is 1213% higher in plasma than in whole

Small variations also occur between serum and

plasma samples for potassium and some other
substances.
(2)Test method:-e.g. a glucose oxidase enzyme
method will give a narrower reference range for
blood glucose than a Folin-Wu technique because
the enzyme method is specific for glucose.
(3)Performance:-Some tests can be performed
with less variation than others.
The reference ranges for such tests will therefore
be narrower.

ow reference ranges are establish

The reference range for a particular substance
is worked out by testing and plotting a graph of
frequency of value against concentration.
For some assays the graph produced is
symmetrical in shapes howing the highest
number of people having values around the mean
(average) with a gradual decrease in frequency
on each side of the mean.

In statistical terms the distribution of values

around the mean can be expressed as standard
deviation (SD).
When the results of a particular test show a
symmetrical (Gaussian) type curve, the reference
range for the substance being measured is

This covers 95% of the healthy population(1

SD covers 68% of the population, and 3 SD
covers 99.7% of the population).

ssessing reference (normal) range

Because reference ranges are affected by a
variety of biological and analytical factors, they
should be regarded only as approximate interim
reference ranges to be assessed by clinicians and
laboratory staff at a later stage when sufficient
data becomes available.
The central laboratory should assist in
confirming reference values for the population.

Note:-The reference ranges given in this

publication have been compiled from accepted
western values and those received by the author
from a small number of tropical countries.

Interpretation of results outside

the reference range
If a patients result is outside of the accepted
reference
range this does not necessarily indicate ill health.
The patient may be in the 5% minority healthy
group outside the Mean 2 SD range.

There can be no clear dividing line between

normal and abnormal values.
This is one of the reasons why the term
reference range is preferred to normal range.
To interpret test results adequately, not only
should the reference values provided by the
laboratory be considered by clinicians, but also
the levels of abnormality which are likely to be
present in different diseases and in the early and
late stages of a disease.

Action to take when results are

seriously abnormal
As part of standard operating procedures and
QA, laboratories need to decide what procedure
should be followed when a result is seriously
abnormal or unexpected, e.g. when compared
with a previous recent result.
For some tests it may be appropriate to define a
level of abnormality which leads to immediate
action being taken by laboratory staff to check
the result and inform the person treating the
patient.

Important
Whenever a result is communicated orally, the
written report should be issued as soon as
possible.
Before being issued, all reports must be
checked (verified) by the most experienced
member of the laboratory staff.
Verification of reports is particularly important
when trainees are performing tests.