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Internal quality control of PCR-based genotyping methods in research studies and patient diagnostics.

Genetic analyses are increasingly integrated in the clinical laboratory, and internal quality control programmes are needed. We have focused on quality control aspects of selected polymorphism analyses used in thrombosis research. DNA was isolated from EDTA-blood (n = 500) by ammonium acetate precipitation and analysed for 18 polymorphisms by polymerase chain reaction (PCR), i. e. restriction fragment length polymorphisms, allele specific amplification, or amplification of insertion/deletion fragments. We evaluated the following aspects in the analytical procedures: sample handling and DNA-isolation (pre-analytical factors), DNA-amplification, digestion with restriction enzymes, electrophoresis (analytical factors), result reading and entry into a database (post-analytical factors). Furthermore, we evaluated a procedure for result confirmation. Isolated DNA was of good quality (42 microg/ml blood, A260/A280 ratio >1.75, negative DNAsis tests), and the reagent blank was contaminated in <1% of the results. Occasionally, results were re-analysed because of positive reagent blanks (< 1%) or because of problems with the controls (<5%). On confirmation, we observed 4 genotyping discrepancies. Control of data handling revealed 0.1% reading mistakes and 0.5% entry mistakes. Based on our experiences we propose an internal quality control programme for widely used PCR-based haemostasis polymorphism analyses.

Alleles↗

Quality control programme for acute pain management in emergency medicine: a national survey.

OBJECTIVE: This national survey was carried out to evaluate the quality programme for acute pain management in the emergency department (ED) and in pre-hospital emergency medical services (EMS). METHODS: Two types of questionnaires were sent to the chief consultant and the chief nurse of all ED and EMS. Data collected were: the type of structure, quality programme organization, acute pain management, and the training needs to initiate a pain quality programme. RESULTS: A total of 363 questionnaires were recorded (198 from chief consultants) with 98% of questionnaires being usable. A pain management committee existed in 71% of cases, a quality committee in 83%. A complete quality control procedure existed in 53% of units. An audit on pain management was carried out in only 23% of cases. Training in quality was performed for 64% of physicians and 68% of nurses. Training specifically for pain management was carried out for physicians in 56% of cases and for nurses in 68% of cases. Pain therapeutics protocols existed in 69% of cases. Pain intensity was evaluated 'systematically or often' in 64% at the beginning of patient management, and in 56% at the end of patient management. The staff was 'not very motivated' for a pain management quality programme in less than 3% of responses. A total of 61% of chief consultants and 58% of chief nurses requested advice. CONCLUSION: Most ED and EMS units seem to master the quality control programme methodology. Units are highly motivated to initiate a quality control programme on pain. Nevertheless, its implementation could benefit from some external support.

Acute Disease↗

Technical quality control in mammography screening: first results in Belgium.

In this paper the first results of the application in Belgium of the European protocol for the technical quality control of mammography screening are presented. Twelve mammography screening units were submitted to an acceptance test: one fourth complied with the criteria after a second visit. A daily quality control procedure has been run since eighteen months. The most important detected problems are given and discussed. The European Commission, in the framework of "Europe Against Cancer", recently published the "European Guidelines for Quality Assurance in Mammography Screening" (1). In another contribution (2), a brief overview of the important appendix "European Protocol for the Quality Control of the Technical Aspects of Mammography Screening" was given. In this paper the first results for the application of this protocol in Belgium are presented.

Female↗

Quality control system for mass screening in Japan.

Japan was the first country to establish a nationwide quality control system. When the Japanese Federal Government initiated Nationwide Neonatal Screening in 1977, the system officially included a Quality Control (QC) System that should cover all screening laboratories in Japan. This QC system is quite different from that for usual clinical chemistry. The aim of the National QC System for Neonatal Screening is evaluation of the accuracy of the tests and evaluation of the ability to detect suspicious samples with very mild abnormalities. For accomplishing the aim, the QC center established an inter-laboratory QC survey Screening laboratories having weak points can be identified through the inter-laboratory QC survey, and the Center must find a way to improve the ability of these screening laboratories. This requires a nationwide consensus regarding the cut-off levels of tested materials. Based on the cooperation of the Societies For Mass-screening, of Inborn Errors of Metabolism and of Pediatric Endocrinology, we set low cutoff levels for each compound to minimize the number of false negative cases. The system also included the evaluation of the quality of essential screening reagents and the special filter paper for blood collection (in partnership with the production companies). For this purpose, we developed some new methods for evaluating the standard-compounds for the various screening tests exactly, except in the case of TSH screening.

Humans↗

A regional quality control trial of folate assays.

A regional quality control trial of folate assays is described. It is concluded that the trial is practical and useful in allowing inter-laboratory comparison of results, promoting discussion, and improving precision but it is impossible to assess accuracy. It was of no use in the comparison of assay methods, probably on account of the small number of laboratories participating.

Blood Chemical Analysis↗

Quality control in microbiology: a review and bibliography.

Quality control in microbiology, with the proliferation and widespread usage of commercial identification systems, has largely passed into the hands of the manufacturer. In this review the author attempts to provide a spectrum of information concerning the validity, precision, and specificity of commercially available systems and individual methods for the identification of bacteria, of various types of yeasts, and of bacterial antigens, as well as a review of blood culture systems.

Bacteriological Techniques↗

PACP regional quality control program: a general survey.

A regional quality control program operated by the Pennsylvania Association of Clinical Pathologists is described. About 120 laboratories in Pennsylvania and a few neighboring states participated in the program. Two 1000-liter lots of pooled normal and abnormal sera meeting or exceeding the specifications of the National Committee of Clinical Laboratory Standards and the College of American Pathologists were prepared and lyophilized. Participating laboratories determined each constituent in the sera every day for a year, from March 1973 to March 1974. The data was processed by a computer. The inter- and intra-laboratory reports containing the mean, standard deviation, coefficient of variation, Youden plots, etc. for each constituent were made available to all the participating laboratories. Practical applications of these statistical parameters in evaluating the quality of the performance of the laboratories are discussed.

Blood Chemical Analysis↗

Paracetamol: a report of a regional quality control scheme.

The results from an external quality control scheme for the assay of paracetamol in serum are reported. A preferential method of assay has not become evident, but, as a result of the scheme, some laboratories have changed or modified their techniques or have re-established the limits of detection. The majority of laboratories were able to estimate paracetamol satisfactorily at those levels which are of clinical importance. The overall group performance has shown little change. The programme has had considerable impact in so far as it has led to a mutually useful interchange of information and trouble shooting.

Acetaminophen↗

A design for interlaboratory quality-control programs.

A design for interlaboratory quality-control programs is described. Speimens are despatched in pairs to participating laboratories. The results returned by laboratories are compared with each other and with reference results, but the frequent brief reports which are prepared are not regarded as the main laboratory assessments, although these reports can alert laboratories to gross imprecision and inaccuracy. When sufficient results have been returned, a linear regression analysis is carried out between results from each laboratory and the reference results. The statistics obtained from the regression data provide a concise source of information about the form of inaccuracy (imprecision and systematic error) present.

Chemistry, Clinical↗

[Quality control in aspiration biopsy cytology].

Comparison and quality control of our experience of thyroid cytology (784 samples) and breast cytology (1,202 samples) were reported. False positive rate and other parameters were superior in breast cytology than thyroid. It may be due to the fact that cytological diagnostic criteria for follicular thyroid carcinoma from follicular adenoma is not established yet. More suspicious diagnosis in thyroid than breast also give low incidence of malignancy in thyroid suspicious diagnosis. As recommended by a guideline for both thyroid and breast cytology from the Papanicolaou society et al, conservative handling and protective diagnosis may help to reduce false positive and false negative rates.

Breast Diseases↗

Computer-assisted quality control in clinical chemistry.

A MUMPS comuter program, which stores and retrieves quality-control data from all automated and manual work-station in the laboratory, has been developed as part of a laboratory information system. Tabular displays, Levey-Jennings charts, and summary statistics are available on a real-time basis. Significant economy over previous manual methods has been observed, and the total quality-control program in the laboratory has become a more active and timely process.

Chemistry, Clinical↗

[Quality control of leukocyte filtration of blood products].

Quality control of leucocyte depleted blood products has become a problem since the introduction of bedside leucocyte filtration. At our Blood Centre, this problem has been circumvented by testing a sample taken as the filtration is completed by sealing off a 10 cm piece of tubing just under the filter. We have tested four brands of erythrocyte filters, Pall RC100, Erypur Optima b, Sepacell R-200A and Sepacell R-500A(II) using two erythrocyte concentrates for each filter. We have tested two brands of thrombocyte filters, Pall PL100 with 6-8 thrombocyte concentrates, and Sepacell PL-5A with 2-6 concentrates. No transfusion should give more than 5 x 10(6) leucocytes. Pall PL100, Pall RC100 and Sepacell R-500A(II) met the criteria.

Blood Transfusion↗

Proposed quality control guidelines for National Committee for Clinical Laboratory Standards Susceptibility Tests using the veterinary antimicrobial agent tiamulin.

Quality control guidelines for standardized antimicrobial susceptibility test methods are critical for the continuing accuracy of these clinical tests. In this report, quality control limits were proposed for the veterinary antimicrobial agent tiamulin with minimum inhibitory concentration (MIC) ranges of three or four log(2) dilution steps in two different medium formulations. Disk diffusion zone diameter ranges were proposed for tiamulin tested against Actinobacillus pleuropneumoniae ATCC 27090 (12-18 mm) and Staphylococcus aureus ATCC 25923 (25-32 mm). The data from eight participating laboratories produced 100% of results within proposed MIC limits (8-32 microg/mL), and 95.8-97.0% of zones were found within suggested zone diameter QC guidelines. These proposed QC ranges should be validated by in-use results from veterinary clinical laboratories.

Actinobacillus Infections↗

Microbiological quality control study of "all-in-one" total parenteral nutrition admixtures.

A microbiological quality control study of parenteral nutrition (PN) is presented. The study was carried out in the Pharmacy and Microbiology Services of the Hospital de la Santa Creu i Sant Pau (Barcelona, Spain) from April 1991 to May 1998 and represents more than 25,000 lipid-containing PN admixtures prepared during that 7-year period. A randomized sampling procedure according to the cumulative sum control charts was performed and a 0.45-microm membrane filtration method was used as the microbiological test. Validation showed that the method is sensitive for sterility tests. Bacterial growth was observed on 59 filters (4.58% of the samples). A second control was made for these positive outcomes, and bacterial growth was found in only two cases. The patients' clinical history was reviewed and no relation between the microorganisms of the nutrition and the results obtained from blood cultures was observed. The quality control study revealed a low incidence of contamination in our PN preparation process.

Bacteria↗

Cost effectiveness of quality control in bacteriology.

The cost effectiveness of quality control in bacteriology stipulated by regulators is not established. The authors evaluated 111 surveillance procedures applied to 54 different operations; 100 had been performed in the authors' lab between 1965 and 1980, 91 of which had been performed 50 times. Forty-six conformed to CLIA requirements (CLIA-P). Thirty-seven others were CLIA-P, which had been modified (CLIA-PM) by reducing frequency and extent because few or no deficiencies had been observed. Eight others were devised by the authors (HH-P). The number detecting deficiencies, the per cent, and the mean per cent of deficiencies detected were: CLIA-P, 31, 67%, 3.5%; CLIA-PM, 8, 22%, 2.1%; HH-P, 8, 100%, 8.8%. Compliance with CLIA would cost HH $20,700/year (3.4% of total bacteriology laboratory cost). HH-P would cost an additional $9000/year. Discontinuation of CLIA-P not detecting deficiencies would reduce HH costs by $2900/year. Application of other low yield CLIA-P only to new lots of selected dehydrated media and fresh batches of selected reagents would reduce cost further by $2000/year.

Bacteriology↗

Performance characteristics of Bull's multirule algorithm for the quality control of multichannel hematology analyzers.

The multirule quality control procedure for interpreting Bull's moving averages, proposed by Levy and colleagues (Am J Clin Pathol 1986; 85: 719-721.), has been evaluated by computer simulation with the use of the approach of Cembrowski and Westgard (Am J Clin Pathol 1985; 83: 337-345.). With this procedure, a batch of patient specimens is rejected if either of two criteria are satisfied: (1) the Bull's mean of one of the red blood cell indices is outside its 3% limits, or (2) the average of three consecutive Bull's means is outside its 2% limits. Power function curves were used to summarize the performance of the multirule approach and demonstrated error-detection capabilities that are superior to the more common implementation of Bull's algorithm using 3% limits for single Bull's means. The increased error detection achieved by the multirule procedure allows shifts in hemoglobin and mean corpuscular volume to be more readily detected but also results in the detection of small shifts in red blood cell count. A modified multirule procedure was also tested and was found to be ineffective. The authors recommend the multirule of Levy and colleagues but caution that its use may result in the detection of small shifts in the red blood cell count.

Algorithms↗

Rapid (partial) prescreening of cervical smears: the quality control method of choice?

Rapid rescreening of all negative and inadequate smears is the quality control method of choice in the UK. The sensitivity of primary screening of laboratory and individual screeners are major indicators of screening quality and are dependent on the number of false negative smears found by rapid screening for their calculation. High sensitivity may indicate good quality primary screening or poor quality rapid review. Quantifiably high quality rapid rescreening is essential if these sensitivity figures are to be meaningful. A 12-month study was undertaken in routine practice using the prescreening mode to ascertain the sensitivity of rapid (partial) screening in our department. The final results of smears were compared with those of rapid prescreening. The calculated sensitivity ranged from 92-54% for high-grade abnormalities and 75-33% for all grades, revealing a wide range of performance between individual prescreeners. Rapid prescreening can identify individuals best suited to rapid screening in routine practice. By using these prescreeners only, the sensitivity of cervical screening could be raised. Rapid (partial) prescreening should be considered as the quality control method of choice.

False Negative Reactions↗

Three Rs potential in the development and quality control of immunobiologicals.

Immunobiologicals (vaccines, immunoglobulins and -sera) are considered to be the most cost-effective tools in the prevention of infectious diseases. Their importance will further increase due to various eradication programmes of the WHO and EU and the emergence of new infectious diseases or the re-emergence of diseases as diphtheria and tuberculosis. The production and quality control of immunobiologicals are regulated by monographs and guidelines, which are issued by international or national Pharmacopoeias (e.g. Ph. Eur.), international organisations (e.g. WHO, O.I.E.) and international regulatory bodies (e.g. EMEA). Their purpose is to assure the quality of the product, i.e. its safety and potency. It is estimated that 10 millions of laboratory animals are world-wide used for the production and quality control of immunobiologicals, of which 80% are needed for the safety and potency testing of the finished product (batch control). In recent decades, the use of Three Rs principles has been recognised by the above mentioned organisations and various national competent authorities and been incorporated into general monographs and guidelines. Several tests with questionable relevance have been deleted from Ph. Eur. monographs (e.g. abnormal toxicity test, extraneous agents testing of viral vaccines for carnivores) or are now carried out during production. Reduction of the number of animals used could be achieved by introducing single-dilution tests. A large number of immunochemical tests have been developed, which could completely or partly replace the use of animals for potency testing, however, only a few have been validated so far (e.g. ToBI and ELISA for potency testing of human and veterinary tetanus vaccine; ELISA for potency testing of erysipelas vaccine). Regulatory acceptance of validated alternative methods is still a critical step. In particular, the period between successful validation and the implementation appears to be far too long. Reasons for this could be the slow process of multinational agreement to revise pharmacopoeial monographs and guidelines, and the time-consuming and expensive production of sufficient reference material (antigen, sera etc) for the new test systems. The shift in the quality control concept from reliance on final batch testing to the concept of consistency of production offers the opportunity to reduce the numbers of animals being used and promote the use of alternative methods. Emphasis is put on a combination of in vitro tests, which could make it possible to monitor batch-to-batch consistency. This new concept of quality control is already in place for the new well-defined vaccines. In most cases, non-animal methods are used for monitoring consistency at critical steps in the production and testing of a vaccine. Whether the concept of consistency of production could be also applied to the conventional, less-defined products, should be investigated. Only little progress has been achieved with regard to international harmonisation. Most of the manufacturers produce for the world market, so harmonisation of the requirements or mutual recognition of tests would help to reduce the use of animals. There is agreement that for the time being animals will still be needed for the development of vaccines in order to gain best knowledge on the disease, the pathogen and the specific immune response, including: pathogenesis, identification of the protective antigens, the way the antigen is processed, the dynamics of the immune response, the induction of memory, and the selection of the best adjuvant. With regard to routine batch release of conventional products, a number of Three Rs approaches are already available and should further be developed and validated. Whereas routine batch release of new products should be based on in vitro methods already established during their development.

Animal Testing Alternatives↗