The College of American Pathologists laboratory accreditation program

The College of American Pathologists (CAP) operates voluntary programs in proficiency testing (PT) and quality monitors, which are briefly described. Additionally, a peer-based laboratory accreditation program covers over 6,100 clinical laboratories. Participation requires successful PT and on-site inspections using a series of 18 checklists structured along traditional subdisciplines of laboratory medicine and anatomic pathology. The laboratory general checklist contains over 250 questions covering broad issues affecting all disciplines. Among these are three items within the computer services section that specifically probe the laboratory’s use of autoverification. Data autoverification is defined as the process by which the computer performs the initial verification of test results; any data that fall outside of set parameters should be reviewed by the human operator. Central to these questions is the role of the laboratory director in approving the rules and validation. CAP does not define the specific technical details, recognizing the uniqueness of each laboratory setting and the patients it serves. Received: 8 August 2002 Accepted: 10 August 2002 Presented at the European Conference on Quality in the Spotlight in Medical Laboratories, 7–9 October 2001, Antwerp, Belgium Correspondence to A. Rabinovitch     

A review of autovalidation software in laboratory medicine

Although autovalidation procedures have been around for many years, through the use of computers and the application of (medical) protocols, they are now becoming part of the production environment of medical laboratories. The introduction of high volume instruments within routine medical laboratory testing certainly speeded up their application as well. After defining autovalidation, autoverification and autoconfirmation, this paper provides a framework for the different ways and places where these tools can be applied within laboratory medicine. Technology as well as organization are essential building blocks to reach well-defined, transparent and assured quality. A laboratory automation system (LAS) brings both areas together in a logical, future-oriented way. Strengthening the information loop, reaching guaranteed quality (analytical, turnaround times and efficiency), leads towards strict management of the laboratory processes. This includes all laboratory processes and here autovalidation and autoreporting become essential. A survey of currently available software routines and their appraisal from a managerial viewpoint are given. It can be concluded that autovalidation software in laboratory medicine is maturing and is rapidly becoming a critical success factor in any medical laboratory. Quality can be automated for sure and autovalidation software will prove to be a valuable aid to do so. Received: 23 August 2002 Accepted: 26 August 2002 Presented at the European Conference on Quality in the Spotlight in Medical Laboratories, 7–9 October 2001, Antwerp, Belgium     

Biological variation data are necessary prerequisites for objective autoverification of clinical laboratory data

The wealth of quantitative data on random biological variation has been used for setting quality specifications, assessing the utility of conventional reference values, and deciding of the significance of changes in serial laboratory results. Most analytes have marked individuality and this makes conventional population-based reference values of low utility. In consequence, reference limits are not ideal for autoverification strategies. Clinical decision limits may be better criteria for holding results for verification by laboratory professionals. Changes in serial results are significant only when the reference change value is exceeded. Such values can be generated by all laboratories and can be implemented, not only to flag reports, but also in delta checking and autoverification since these are objective rather than empirical. We have put these considerations into operation into our laboratory. Apart from special cases, our general approach is that results flagged as having changed 0.05<P<0.01, flagged as just outside the reference limits, or not flagged in any way, are autoverified and reported to the user without intervention. Only results outside pre-set clinical limits and those that have changed highly significantly P<0.01 are held for verification by clinical scientists and medical staff. This strategy allows autoverification of ca. 60% of reports. Received: 15 May 2002 Accepted: 17 July 2002 Presented at the European Conference on Quality in the Spotlight in Medical Laboratories, 7–9 October 2001, Antwerp, Belgium Correspondence to C. G. Fraser     

Tracking and controlling everything that affects quality is the key to a quality management system

Every laboratory has a need to track and control the variables that drive the quality of the results. However, each laboratory is unique and what one organization deems to be a critical process to track and control will likely differ from other organizations. Furthermore, there is more than just the end product or result that needs to be tracked and controlled. All of the intermediate products and resources play a significant role in producing the final product and each of these needs to be included in the LIMS. At a high level, this article will present ideas and opinions on the following topics in relation to implementing a LIMS process tracking and control system in a laboratory: The difference between tracking and controlling processes; What to track and control in the lab; The "product" of the laboratory; Preventing mistakes in a laboratory; Comprehensive software platform options; The value of seeing a system as opposed to imagining it; The use of barcodes in the laboratory; and an assessment on using the Risk Based Approach in deciding what to include in the tracking system.     

Regulatory compliance vs. NEXUS quality for laboratory tests

In the U.S., all clinical laboratory testing is regulated by the Clinical Laboratory Improvement Amendments (CLIA) (). The CLIA link test quality and adherence to a body of testing regulations intended to ensure accurate, reliable, and timely patient test results. The goal of the CLIA legislation was to ensure a minimum, fundamental level of quality. In the context of “NEXUS,” quality must “go beyond getting the ‘right’ answer on the ‘right’ patient that can be interpreted against ‘right’ reference values. CLIA regulations with specific minimum, performance requirements, or safeguards, are designed to prevent testing errors. The US Institute of Medicine found that testing processes fail as a result of human error, lack of documentation, and lack of test management. In the latest (2004) interpretations of CLIA regulations, the minimum quality control requirement continues to be analyzing at least two external, liquid quality control materials per test per day. In 1995, we proposed that the responsibility for achieving quality test results shifts from the sole purview of the laboratory director to an “alliance” of laboratory professionals, manufacturers, and regulators. The EQC (equivalent quality control) concept as proposed is a positive step in achieving this alliance. With the obvious lack of scientific and statistical robustness, EQC falls far short of ensuring quality. Achieving the “NEXUS Vision” for quality laboratory testing will not come solely from laboratory professionals. The NEXUS is about how to ensure the full-quality assessment of the testing process – pre-analytical, analytical, and post-analytical.Presented at the 10th Conference Quality in the Spotlight, March 2005, Antwerp, Belgium.     

Irradiation plant control upgrades and parametric release

This paper reviews an integrated PC irradiation plant control system which is one of the most advanced available. The system controls the entire irradiation process from ‘goods in’ through to dosimetry and the production of post-irradiation documentation. Product processing speeds are automatically calculated by reference to validation data which ensures that the dose requirements are met. Detailed product tracking and data logging of all plant activities ensures traceability of the entire irradiation process. The paper demonstrates how the system effectively enables parametric release of products since the critical processing parameters are automatically set, monitored and recorded and are directly linked to the validation of these parameters.     

Warning: false sense of certainty from the illusion of accuracy and precision in measurements

The illusion of accuracy and precision in testing is often associated with overconfident safety checks before catastrophes: National Aeronautics and Space Administration (NASA) “no safety-of-flight issues,” Deepwater Horizon site in Gulf Mexico reported as “industry model for safety” a year before its explosion, and Fukushima nuclear plant safety test found “satisfactory” at seismic magnitude viewed highest possible. In health care, testing overuse and misuse play significant roles in overconfidence and mistakes. Gaps between systems are most susceptible to errors, such as in miscommunications between the laboratory and the clinic. A safety culture is characterized by ability to communicate, anticipation of misunderstanding and resilient learning from failures. The discussion will show how messages from the laboratory may reduce the false sense of certainty from a test result; how results of tests are meaningless without pre-test estimates; how multiplicity of routine tests increases chances of false positivity; and how reporting measurement limitations can educate all users, including laboratory technicians, clinicians and patients, about the importance of quality assurance and about the pervasive nature of uncertainty beyond analytical performance. In conclusion, an illusion of accuracy and precision in testing evokes among clinicians a false sense of certainty leading to overuse and misuse of tests. Messages from the laboratory may reduce overconfidence from test results and lead to safer use of testing.     

Analysis of the release process of phenylpropanolamine hydrochloride from ethylcellulose matrix granules III. Effects of the dissolution condition on the release process

In the pharmaceutical preparation of a controlled release drug, it is very important and necessary to understand the entire release properties. As the first step, the dissolution test under various conditions is selected for the in vitro test, and usually the results are analyzed following Drug Approval and Licensing Procedures. In this test, 3 time points for each release ratio, such as 0.2-0.4, 0.4-0.6, and over 0.7, respectively, should be selected in advance. These are analyzed as to whether their values are inside or outside the prescribed aims at each time point. This method is very simple and useful but the details of the release properties can not be clarified or confirmed. The validity of the dissolution test in analysis using a combination of the square-root time law and cube-root law equations to understand all the drug release properties was confirmed by comparing the simulated value with that measured in the previous papers. Dissolution tests under various conditions affecting drug release properties in the human body were then examined, and the results were analyzed by both methods to identify their strengths and weaknesses. Hereafter, the control of pharmaceutical preparation, the manufacturing process, and understanding the drug release properties will be more efficient. It is considered that analysis using the combination of the square-root time law and cube-root law equations is very useful and efficient. The accuracy of predicting drug release properties in the human body was improved and clarified.     

How gamma radiation processing systems are benefiting from the latest advances in information technology

This paper discusses how gamma irradiation plants are putting the latest advances in computer and information technology to use for better process control, cost savings, and strategic advantages.

Some irradiator operations are gaining significant benefits by integrating computer technology and robotics with real-time information processing, multi-user databases, and communication networks. The paper reports on several irradiation facilities that are making good use of client/server LANs, user-friendly graphics interfaces, supervisory control and data acquisition (SCADA) systems, distributed I/O with real-time sensor devices, trending analysis, real-time product tracking, dynamic product scheduling, and automated dosimetry reading. These plants are lowering costs by fast and reliable reconciliation of dosimetry data, easier validation to GMP requirements, optimizing production flow, and faster release of sterilized products to market.

There is a trend in the manufacturing sector towards total automation using “predictive process control”. Real-time verification of process parameters “on-the-run” allows control parameters to be adjusted appropriately, before the process strays out of limits. Applying this technology to the gamma radiation process, control will be based on monitoring the key parameters such as time, and making adjustments during the process to optimize quality and throughput. Dosimetry results will be used as a quality control measurement rather than as a final monitor for the release of the product. Results are correlated with the irradiation process data to quickly and confidently reconcile variations. Ultimately, a parametric process control system utilizing responsive control, feedback and verification will not only increase productivity and process efficiency, but can also result in operating within tighter dose control set points.     

Utilisation of customer feedback in a university hospital laboratory

The article describes the customer feedback system at a university hospital laboratory and the analysis of the feedback data from clinical customers in 2001–2006. The most common subject matters of the feedback were suspicion of the validity of laboratory results, delay in service and lacking test results, covering 82% of the 115 reports. The investigations of the cases revealed errors or defects in laboratory services in 81 cases. The most common errors or defects were erroneous test results (35 cases; 43%), delayed test results (24 cases; 30%) and lacking test results (15 cases; 18%). The most common underlying causes for a laboratory error or defect were unintended errors and non-compliance with operating instructions. Seventy-six percent of the feedback reports led to corrective actions. It is important to react to every instance of customer feedback and to find out possible errors or defects in the laboratory process. Uncovering the underlying causes makes adequate corrective and preventive actions possible.     

Determination of formaldehyde release from wood-based panels using SPME-GC-FAIMS

Several standardized methods exist to determine formaldehyde (HCHO) release from wood-based panels (WBPs). These methods were developed decades ago to be used in manufacturers laboratories to provide a mean of production control. They are robust and take several hours to yield results. Modern WBP panel production, however, is a continuous process. Therefore the established methods are too time-consuming for process control and process optimization with respect to HCHO release. Moreover, there is a strong trend of lowering the regulatory HCHO emission limits. Thus, there is a need for a comparatively fast and precise method which is suitable for the use on-site in a WBP manufacturers laboratory. In this work, an optimization of the solid phase micro extraction gas chromatography high field asymmetric waveform ion mobility spectrometry (SPME-GC-FAIMS) method is presented with respect to GC-FAIMS settings and the calibration procedure. It is also shown that, in addition to WBP block samples, also particles can be used for the measurement. The industrial applicability of SPME-GC-FAIMS system was demonstrated by testing the HCHO release of freshly produced WBPs on-site in the manufacturers laboratory.     

Statistical treatment of proficiency testing data

 There are three stages to evaluating a laboratory's results in an interlaboratory proficiency test: establishing the correct result for the test item, determining an evaluation statistic for the particular result, and establishing an acceptable range. There are a wide variety of procedures for accomplishing these three stages and a correspondingly wide variety of statistical techniques in use. Currently in North America the largest number of laboratory proficiency test programs are in the clinical laboratory field, followed by programs for environmental laboratories that test drinking water and waste water. Proficiency testing in both of these fields is under the jurisdiction of the federal government and other regulatory and accreditation agencies. Many of the statistical procedures are specified in the regulations, to assure comparability of different programs and a fair evaluation of performance. In this article statistical procedures recommended in International Organization for Standardization Guide 43, Part 1, are discussed and compared with current practices in North America. Received: 22 April 1998 · Accepted: 12 May 1998     

Predictive values instead of normal ranges: less data, more information

Diagnostic strategies can have various goals at two levels: to facilitate the diagnostic process on the cognitive level, and to serve considerations on the level of the doctor–patient relationship. Requests for laboratory tests could be intended to exclude a disease or to affirm the presence of disease. Thirdly, tactical motives to smoothen the negotiations between doctor and patient probably seem to be important as well. These three intentions differ in prior probability, should lead to different sets of tests, and to different interpretations. Even the cut-off points should differ. This leads to three different decision strategies, both at requesting, as at interpreting the results. Following this line of thought, post-test probabilities are more suitable than normal ranges. Excluding strategy: this is the most prevalent. However, the disadvantage of an excluding strategy (prior 1–5%) is a false-positive result. A positive test result should lead to follow-up by wait and see or by repeated testing. More extensive testing usually is not a very sensible strategy. In practice, physicians simply ignore slightly abnormal values. Mentally they put the cut-off points for normality more broader. The number of tests is small. Confirmative strategy: the disadvantage of a confirmative intention (prior 10–30%) is a false-negative result. Follow-up without testing, repeated testing, or even accepting marginal normal results as abnormal is a proper strategy. The number of tests is moderate to high. Tactical strategy: the tactical intention strategy to reassure the patient – or avoid referrals – could lead to ignoring all slightly positive test results by choosing a higher cut-off point. Actually, considering the usual insignificant diagnostic gain when testing for tactical reasons, all test results are clinically insignificant, unsuspected outliers excluded. Here, a very limited set of tests should be chosen. The laboratory test is the currency in mutual trading medical expectations and relationship considerations between doctor and patient. The number of tests is minimal. If the physician chooses a strategy, a limited range of prior probability is chosen. Then a possibly computerized algorithm produces a “Value (posterior probability)” as test result, replacing “Value (normal ranges)”. Thus one number less on the lab form, yielding more significant information.Presented at the 10th Conference Quality in the Spotlight, March 2005, Antwerp, Belgium     

LabRespond: a tool for autoverification

Autoverification is defined as the process by which a computer performs the initial verification of test results. Any data that fall outside set parameters are then reviewed by the technologist [1]. LabRespond is an open system with an integral approach to control which monitors all the phases of the laboratory process. In particular, the statistical-based multi-two-dimensional test ”frequency of occurrence” has a high detection rate for suspicious test results. The content of LabRespond, the validation rules and, in particular, the test ”frequency of occurrence” is mainly the work of members of the Dutch Working Group of Clinical Chemometrics¹(¹Members of the Dutch Working Group of Clinical Chemometrics are: Marcel Volmer, Martin van der Horst, Remi Wulkan, Kees van Dongen, Wytze Oosterhuis, Herman Ulenkate and Henk Goldschmidt.) and the staff of the laboratory of the Saint Elisabeth Hospital in Tilburg. Received: 30 July 2002 Accepted: 7 August 2002 Presented at the European Conference on Quality in the Spotlight in Medical Laboratories, 7–9 October 2001, Antwerp, Belgium     

后疫情时代微信融入无机化学实验教学的初探

针对后疫情时代的教学需要和地方高校的信息化教学资源的不足,通过创建微信公众号和微信群,初步探索了微信融入无机化学实验教学的新模式。课前通过公众号的推文引导学生进行有目标的预习,养成自主学习和独立思考的习惯。课堂中,先通过微信群进行预习测试,并基于测试反馈调整需要重点讨论的实验要点,再通过微信群共享师生在实验过程中对实验操作、实验现象和实验结果拍摄的照片或视频,充分激发学生兴趣,提升学生的能力。课后结合拍摄的错误操作的照片撰写公众号推文,进行实验反馈,帮助学生形成反思的习惯。     

The development of heat flow calorimetry as a tool for process optimization and process safety

Classical thermo-analytical micro methods (DTA, DSC) are still very useful for process work, but medium scale instruments based on heat flow measurement are attaining an increasingly important role in this domain. As in many areas, development of reaction calorimetry for industrial applications was driven by needs and by available means (technical capabilities). The needs have been fairly constant over the past decades. There are data needs:

Reaction rates

Heat release rates

Heat of desired reactions and decompositions

Heat capacities and heat transfer capacities

It took the specialists of calorimetry a long time to recognize and to accept the operational needs, namely:

Working under controlled temperature conditions (constant temperature, temperature ramps)

Adding components during runs (continuously or in portions)

Simulation of industrial mixing conditions

The main driving force for the development of process oriented calorimetric instruments was the evolution of electronic hardware which made the control of heat flow on a (non micro) laboratory scale easy. The paper gives an overview on the principles of heat flow control and reviews the developments of the fifties and sixties, when the matching of heat flow with heat release by reactions was the goal. With the advent of fast and powerful laptop computers, the focus has shifted. Now, the deduction of true heat release rates from signals which may be badly distorted, is the goal. Some recent developments are reviewed and the hope is expressed that calorimetric equipment, inexpensive enough to be affordable for every laboratory engaged in process work, will be available soon.     

Quality assurance in clinical chemistry laboratories in the UK

 Since the mid-1960s quality assurance in clinical chemistry has progressed from a need to define and improve precision and accuracy in analytical test procedures to an all-embracing process of assuring that the whole process of pre-analytical, analytical and post-analytical phases of handling patient samples is managed effectively and efficiently. Automated and computer-controlled equipment has reduced many of the analytical errors, in particular in imprecision, that were present in manual analysis. New management techniques have been developed to control the quality and appropriateness of results. Developments in internal quality control and external quality assessment procedures have enabled laboratories to continually improve the quality of assays. Laboratory accreditation and external quality assessment scheme accreditation have ensured that peer review and peer pressure have been applied to both laboratory and external quality assessment scheme performance. As the NHS reviews its priorities and places more emphasis on primary care provider demands, hospital laboratories will of necessity assist with near patient testing outside the laboratory. This will provide new challenges to the quality of the service provided. Received: 2 July 1998 · Accepted: 1 August 1998     

Evolved gas analysis (EGA) of brick clays

Using a system based on non-dispersive infrared (NDIR) detectors, evolved gas analysis (EGA) was able to identify and quantify the principal volatiles produced by heating powdered samples of UK brick clays. From these results, atmospheric emissions likely to result from brick production can be predicted. In addition, EGA results for extruded brick clay test pieces are significantly different from those of powdered samples. Within an extruded brick clay body, evolved gases are contained within a pore system and evolved gas-solid phase reactions also occur. This EGA study provides further evidence on the nature of firing reactions within brick clay bodies. The qualitative and quantitative influence of heating rate — a key process condition in brick manufacture — on gas release is also outlined.Dedicated to Dr. Robert Mackenzie on the occasion of his 75th birthday     

Sol–gel development activities at IGCAR,Kalpakkam

Sol–gel based fuel fabrication processes have the potential to be the nuclear fuel fabrication processes in the future. Hence development of sol–gel technology for nuclear fuel fabrication is being the pursued in the Department of Atomic Energy in India. As a part of the efforts, a laboratory scale facility for fabrication of test fuel pins for irradiation in the Fast Breeder Reactor (FBTR), Kalpakkam has been set up at the Indira Gandhi Centre for Atomic Research, Kalpakkam, India. These fuel pins will be vibropacked with sol–gel derived microspheres or stacked with pellets obtained by compaction of sol–gel derived microspheres. The facility is aimed at demonstration of the remote operation of the fuel pin fabrication process through the sol–gel route. A capsule containing three test pins from this facility will be irradiated in FBTR. The design features of the facility and the test fuel pins are described in this paper.     

Aspects of auditing in clinical laboratories

Quality and patient safety are terms that both providers and recipients of healthcare are very familiar with. Accreditation is another term that is closely linked to quality and patient safety. Audit is a systematic, independent, and documented process for obtaining evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled. Accreditation and audit are integral components of the same process. Three different types of audit are well recognized—internal, external, and co-operative. Reading of relevant documents, observation of laboratory practices, and asking open-ended probing questions are important auditing techniques. For auditing to be successful, experienced, qualified, and well trained auditors are essential. Furthermore, the auditor should be open-minded, not prejudiced, a team player and effective communicator, both in writing and verbally. In many instances, the emphasis for seeking laboratory accreditation has shifted from building quality systems—to produce reliable results and ensure patient safety—to just passing the inspection. Recently, the emphasis for laboratory quality improvement has been placed on pre and post-analytical processes in preference to analytical quality. The analytical quality of laboratory results is still far from ideal and it may be detrimental if less emphasis is placed on this aspect of laboratory medicine. Auditing or on-site inspection as a regulatory tool does not work or present a realistic picture of laboratory quality. A continuous quality improvement approach will help laboratories to build quality into their systems. Presented at the Conference “Excellence in Laboratory Medicine”, November 2007, Al Ain, United Arab Emirates.