Quality Control2

Quality control
Quality control in clinical

chemistry
A standard laboratory must have well
established systems or procedures to
ensure that the test results it issues
are correct.
Quality control in the term used to
describes these procedures.
An overall term used to describe test
controls from both inside & outside
the laboratory to ensure reliable
result in Quality Assurance.
Quality control can be discussed in

three parts:I. Pre analtical.
II. Analytical.
III. Post analytical.
Pre analytical quality control

This topic deals with patient status
and the collection of specimens.
Patient status
Refers to the physiological state of
the patient at the time of collection
of specimen for diagnostic
investigation.
This is to minimise variation in the
final result.
Factors such as food intake or

physical activity may increase or
decrease the levels of certain body
fluid compartments being analysed.
For most blood chemistry
investigations , absolute fasting is
not essential as the results are not
significantly affected , but for tests
such as glucose , triglycerides and
inorganic phosphorus tests , the
patient has to be in fasting state ,
Intake of food and day time

variation may lead to alternation in
the constitution of chemical
substances in the blood.
It is therefore more appropriate to
collect blood specimens in the
morning before the patient takes any
food ; but usually a 4 to 6 hour fast
will suffice.
In case of a plasma lactate test , the
Collection of specimen
It should always be borne in mind that
all clinical specimens are potentially
pathogenic.
It is there fore important that all
necessary safety precautions must be
observed when collecting specimens.
In addition , proper identification of the
patient must be made before collecting
specimen from him / her .
A properly filled request form must
accompany each specimen.
Blood specimen
In case of blood specimens , specimen
containers used for blood for
biochemical investigation must be
leak proof and chemically clean.
Syringes and needles for collecting
the blood samples must be also
chemically clean , dry and sterile.
Venepunture is the accepted method
of blood collection.
Some factors that affect the correctness of

test results do originate from blood
collection.
These factors include:I. Wrong venepuncture techniue.
II. Haemolysis of red blood cells.
III. Use of wrong containers.
IV. Instability of some substances in blood.
. The use of disposable needles and
syringes minimises the risk of infections
due to serum hepatitis virus and human
immunodeficiency virus (HIV).
For the same reasons , plastic tubes

and bottles are preferred to glass
ones.
Venepuncture technique
It is easier to enter a vein which can be felt
that the one that is only seen.
The tourniquet should not be applied too
tightly nor too long in order not to cause
venous stasis which can lead to
concentration of certain blood substances
such as haemoglobin , plasma proteins and
calcium.
It is wrong to collect blood for chemical
analysis from the arm into which an
intravenous infusion is already being given.
Haemolysis of Red Blood Cells

Red blood cells are not often used for
biochemical investigations as the
rupture of the red blood cells can
lead to unreliable results.
This is because haemolysis causes
substances from the cells to be
released into the serum or plasma
thereby giving a false increase in the
concentration of the substances
being tested.
To avoid haemolysis:I. Use good , clean , sterile and dry syringe and
needle.
II. Withdraw blood slowly and steadily.
III. Allow sufficient time for the blood to clot and
retraction of the clot to occur.
IV. Avoid prolonged centrifuging ; 3 to 5 min at 700g
is adequate.
V. Dot not shake blood samples , instead , mix
gently if the container contains an anticoagulant.
VI. Do not freeze whole blood samples.
Specimen containers
Most biochemical analyses require serum.

Blood is therefore collected into dry ,
clean containers.
There are some tests , however , that
require plasma.
To obtain plasma , anticoagulants are
used to prevent clotting.
Whenever possible , using plasma instead
of serum is more advantageous because
the yield of plasma from a given volume
of blood is greater , and the tests can be
performed immediately.
Lithium heparin is the most ideal

anticoagulant as it does not affect
chemical reactions , it helps to
reduce the action of haemolysis and
lacks sodium or potassium salts
which might interfere when
electrolytes are to be measured.
But due to its high cost , other
anticoagulants such as EDTA
(ethylene diamine tetra acetic acid)
and fluoride oxalates are widely used
even though they contain sodium
and potassium salts.
Fluoride is an enzyme inhibitor which

prevents glycolysis (breakdown of
glucose to lactic acid by enzyme
action).
Therefore it must not be used where
enzyme activity is to be estimated.
Preservation of blood
Chemical substances in blood are present

in both plasma and cells in varying
quantities.
Prompt separation of plasma or serum
from cells is important in order to prevent
chemical changes which can occur in
whole blood.
Refrigeration of blood specimen prior to
separation of plasma can lead to false high
potassium level.
Glycolysis can occur if fluoride oxalate
anticoagulant is not used.
Bilirubin will be decomposed on

prolonged exposure to light.
It is essential to refrigerate serum or
plasma at 4C or freeze at 20C
unitl analysed.
As much as possible , blood
specimen should be handled
aseptically to prevent and minimise
chances of bacterial contamination.
Collection of urine specimen can be

early morning , timed or random.
Faecal specimens
CSF
Dispatch of specimens
Analytical quality control

Analytical quality control can be
termed as the internal quality control
carried out within the clinical
laboratory.
It is to ensure that tests are
performed correctly and reliable
results produced.
QC in the laboratory includes:-
I. Training laboratory workers to

perform tests correctly.
II. Establishing performance standards
for each test method.
III. Using control samples to check for
bias , charting results regularly to
check for scatter and taking action
when a test is becoming unreliable.
IV. Whenever possible , taking part in
external quality assessment schemes.
V. Reporting results clearly and with

the minimum of delay.
VI. Making sure that equipment such as
analytical balances , colorimeters ,
heat blocks ( or water baths) , etc
are being used correctly and
maintained adequately.
Post analytical quality

control
Post analytical quality control is an
area which concerns the reporting
and verification of test results before
they are dispatched.
Reporting of clinical chemistry

results
It is important that all results be reported
to the correct number of decimal places.
Each result reported should include the
following:I. Matrix (blood , serum , plasma ,
cerebrospinal fluid or faeces).
II. Analyte(Substance measured).
III. Result clearly presented in SI units.
IV. Reference range.

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Quality control

Quality control in clinical

Quality control can be discussed in

Pre analytical quality control

Factors such as food intake or

Intake of food and day time

Some factors that affect the correctness of

For the same reasons , plastic tubes

Haemolysis of Red Blood Cells

Most biochemical analyses require serum.

Lithium heparin is the most ideal

Fluoride is an enzyme inhibitor which

Chemical substances in blood are present

Bilirubin will be decomposed on

Collection of urine specimen can be

Analytical quality control

I. Training laboratory workers to

V. Reporting results clearly and with

Post analytical quality

Reporting of clinical chemistry

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