J. Carl Barrett,1 Harri Vainio,2 David Peakall,3 and Bernard D. Goldstein4
Standard QC procedures have been well documented. Most published methodologies include QC procedures which must be individualized for each laboratory and each analytic instrument and procedure. Each laboratory must have a written QA/QC statement and protocol. These should be very detailed, including, for example, assurance that the deionized water is free of analytes in question, at least within the limits of detection required. Similarly, the purity of the solvents and reagents and the source of all standards should be specified.
Calibration procedures should use blanks and fresh standards within the range of anticipated concentrations. (One can only assume that a method yields linear results within the range of the calibration curve). The method detection limit should be specified for each analyte in each matrix (blood, urine, hair, etc). Field and method blanks should assure that there is no contamination at any point in the collection and analysis of samples. Spiked samples should assure that the technique can recover the analyte from the matrix. This allows one to document the percent recovery of the spike from the sample. Unless otherwise specified, it is customary to require that each analytic run produce a recovery between 85 and 115% of the actual spike. For some analytes it is difficult to achieve this level of accuracy on certain instruments, while for others tighter limits are routine. If recovery lies outside a certain range of values, then the entire run is rejected, and the stored samples are redigested and reanalyzed. Alternatively, some procedures allow the correction of the analytic results by the recovery percent. Thus if the recovery is only 80% of the spike, the results can be multiplied by 1.25 to correct for the deficiency. This approach is much less desirable and should be avoided, unless there is no further material available for analysis or unless the method repeatedly results in a similar recovery.
Each laboratory should participate regularly in a proficiency testing program involving the blind analysis of unknown samples provided by a reference laboratory. The results of such testing should be maintained with the QA/QC documents and should be available for inspection.
Overall Quality Planning
a) The economic resources available for the program must be identified.
b) The benefits of the program must be justified to assure adequate funding.
c) The intervention must be specified and funds identified in advance, if possible.
d) Where resources are not available for the "best" methodology, the use of alternative tests must be evaluated.
Quality Assurance
a) The screening protocol should include a statement of the data objectives and the required detection limits, the anticipated range of values, and the acceptable limits for precision and accuracy.
b) High quality laboratories should be identified.
c) All participating laboratories should have a written QA/QC document which should include documentation of participation in some Laboratory Proficiency program.
d) The protocol should allow for an internal QC program including blind replicates and confirmation of some percentage of the samples by an external reference laboratory.
e) Data quality evaluation should be completed prior to data analysis.
Standards for Collection of Samples
a) The population to be studied should be clearly identified and the people to be screened should be representative of the population of interest (minimize confounders).
b) All personnel should be selected carefully and should be conscientious and responsible.
c) All personnel (registrars, interviewers, phlebotomists, etc.) should be carefully trained and periodically evaluated.
d) Field sampling conditions should be made as ideal as possible. Use extreme precautions to avoid contaminating samples of blood, urine, etc. at the time of collection.
e) Care must be taken in the transportation of samples from the field to the central laboratory, particularly if samples require freezing or refrigeration.
f) All samples must be carefully and accurately labeled and a chain-of-custody form may be desirable for certain study situations.
Laboratory Standards and Practices
a) High-quality laboratory facilities are essential.
b) Where possible, a laboratory that is already functioning and of proven quality should be used.
c) Whether old or new, laboratories should be designed to eliminate both external and internal sources of contamination. This requires high standards of design and maintenance.
d) Laboratory equipment should be appropriate for the analyses being performed.
e) The appropriate preservation of samples is important, so facilities should have reliable refrigeration, preferably with a backup source of emergency electricity (gasoline generator).
f) All laboratory personnel should be trained; usually this will require training at an analytic center in a major city or outside the country. Training should embody the general principles of laboratory QA/QC and should also be relevant to the equipment available for use in the laboratory.
g) All results should be carefully checked for internal consistency. Deviant results should be repeated.
h) Laboratory supervision should be strict and consistent to assure high quality data.
Results
a) There should be adequate computing facilities and trained personnel for analysis of data.
b) All individual results should be treated as confidential and individuals should be informed of their own results with adequate information as medically appropriate.
c) The suppression of results for economic or political reasons is strongly discouraged.
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