QUALITY CONTROL (QC) INFORMATION

AND TROUBLESHOOTING GUIDE

HEMATOLOGY

This document is not intended to replace the

information in your Instructions for Use Manuals (IFU).

Information in the Instructions for Use Manual(s)

supersedes information in any other manual.
SECTION 1

QC Concepts
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Quality Control (QC) Overview

QC is performed routinely to ensure that an instrument is consistently reporting reliable sample results. Each
laboratory should establish their own QC program, complying with accreditation guidelines.

There are many benefits when a comprehensive QC plan is implemented in the laboratory to ensure the reporting
of accurate sample results, verification of instrument functionality and for troubleshooting irregularities. Refer to
Section 2, Troubleshooting Checklist.

Beckman Coulter recommends participating in the hematology Inter laboratory Quality Assurance Program (IQAP) as
part of the laboratorys quality control plan.

Quality Control Terminology (Please refer to the Glossary see pg 2-7 for definitions of commonly used quality control terms.)

Prerequisites of a QC Program

Functionality
The only way to detect if an instrument is malfunctioning is by understanding its functionality.
Need to know all aspects of the:

principles of operation

startup or daily checks

shutdown

normal sights and sounds of the instrument

Proper Specimen Collection

Analyze only specimens that were properly collected and stored.

V enipuncture collection - ensure proper amount of blood was drawn into the anticoagulated collection tube and
mixed thoroughly; otherwise, cell damage or small clots could occur and the results may be adversely affected.

M
 icro collection or finger stick - ensure cleanliness of puncture area, and keep gauze or tissue particle away
from the blood sample.

References for whole blood collection:

Collect whole blood in EDTA according to tube manufacturers instructions
CLSI publication H4-A5 (for capillary)
CLSI publication H3-A6 (for venipuncture)
CLSI publication H18-A3 - Procedures for the Handling and Processing of Blood Specimen Guidelines

1-1
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Check Sample Results

Check sample results for flags, codes, messages, normal values, and consistency with the patients condition. Need
to be able to:
recognize printed flags, codes, messages on a sample report
understand the meaning of the flags, codes, messages on the report

Delta Checks
Monitor particular patient sample results by comparing the current results to previous results within laboratory
defined limits. Delta check flags are an indication of a significant change if results due to a change in patient
condition or possibly instrument operation.

H&H Check
The H&H check uses patient hemoglobin (HGB) and hematocrit (HCT) results as QC method. Typically,
HCT = ([HGB x 3] +/- 3). H&H failures may be an indication of change in results due to patient condition
or instrument operation.

QC Techniques for the Laboratory

No single QC method can provide all the information for truly effective quality assurance.

A good Quality Control program consists of instrument and control checks, preventive maintenance (if required),
good record keeping, and technologist review. In the hematology laboratory, calibration, commercial controls, patient
controls, XB, XM, extended QC, participation in IQAP and proficiency testing are all techniques that help assure
quality. QC with controls and XB could pick up a trend or shift in the results, and this evaluation of both sources in a
combined method could provide very useful information.

Instrument Checks
Even before you run controls to check instrument accuracy and precision, it is important to verify that the entire
system is working properly. These routine instrument checks are detailed in the Startup or Daily Checks section
of your instrument manuals. If instrument problems are suspected, verify instrument precision and carryover and
troubleshoot according to your laboratory protocol.

QC Procedures
Beckman Coulter hematology systems allow the use of multiple quality control techniques. Beckman Coulter
recommends that Quality Control checks be performed using patient and/or commercial controls at intervals
established by your lab. When using a commercial control, refer to the package insert to determine which method of
sample presentation to use.

NOTE: Failure to recover control values within your labs expected limits or the presence of unexplained shifts or
trends in any method of presentation should be investigated. Patient results obtained between the last acceptable
control run and an unacceptable control run should be re-evaluated to determine if patient test results have been
adversely affected. If necessary, take corrective action.

1-2
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Setting Up Controls
A control is a substance used in routine practice for monitoring the performance of an analytical process or
instrument. Refer to Setup > Quality Control in the respective instrument IFU for information on setting up controls,
and for information on automatic configuration, printing, host transmission, Auto Stop and other features.

Commercial Controls
Beckman Coulter controls are manufactured specifically for use with the full range of Beckman Coulter instrument
and reagent systems. They are available in levels to monitor a range of clinical values. Be sure to read the control
Instructions for Use (IFU) thoroughly. The IFU can be used as a troubleshooting aid. It describes how the product
should be used, how to tell if the product has deteriorated, and lists steps to take when investigating a problem.

Monitoring Adjustments
The Clinical and Laboratory Standards Institute (CLSI) recognizes the need for monitoring QC results, and
recommends periodically recalculating and adjusting QC statistics. When doing so, it is important to include all valid
data collected since the material was put into use. When re-evaluating QC ranges, only omit data points caused by
known operator or instrument error. Do not delete data points simply because they lie outside a 2 SD range. These
outlying points may be part of the normal distribution, and eliminating them from the data set will not account for
true variability.

Introducing a New QC Lot

When evaluating a new lot of the same QC material, it is recommended that data be collected alongside the current
QC lot. The existing QC lot SDs, which have been developed over a long period of time, are a good indication of the
variation to expect from the new QC lot, assuming that the means do not differ significantly.

Establishing QC Ranges
Each laboratory must establish a test-specific acceptable range of quality control values for each type of analyzer.

If the QC results are out of range, investigate if there is a problem with the control material. Try a new vial or lot
number of the commercial product.

Laboratories are required to verify control mean and expected ranges when using commercial controls. Follow
guidelines for quality control ranges as established by:
C
 linical and Laboratory Standards Institute (CLSI)
Statistical Quality Control for Quantitative Measurement Procedures: Principles and Definitions:
Approved Guideline. CLSI document C24-A3 (ISBN 1-56238-613-1). Wayne, Pennsylvania (2006).

C
 linical Laboratory Standards Institute (CLSI)
Laboratory Quality Control Based on Risk Management Approval Guideline. EP23-A (ISBN 1-56238-767-7) Wayne,
Pennsylvania (2011).

C
 ollege of American Pathologists (CAP)
Hematology and Coagulation Checklist. HEM.25870 Commercially Assayed Controls. Northfield, IL (2012).

International Organization for Standardization (ISO)

Medical Laboratories - Particular requirements for quality and competence. ISU 15189. Geneva, Switzerland:
International Organization for Standardization; 2007.

1-3
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Levey-Jennings Chart (QC Chart)

The Levey-Jennings QC Chart is the one most commonly used to show the results of a control for a specified period
in a graphic form. This chart depicts the position of data points relative to the assigned mean. The results are listed
by date and time. The QC Chart is available from either the workstation or data manager.

Outliers
Outliers are discrepant values. Values which do not agree with the pattern of the majority of other values. They may
be due to mistakes or they may represent a significant finding. Figure 1.1 shows a graph of MCV control results
recorded for a 17-day period for a normal control level:

The MCV assigned value is 87 and is used as the mid-line.

The expected range is 3.0 and is used to define the low and high limits.

By using these lines it is easy to quickly identify the outlier on day 12. The reason for the outlier may have been
chance. The probability for this value to be outside the limit is about one time out of every 20 times you run the
control. If your run the control one more time, and the result is in, you can presume the original result was out
by chance.

Figure 1.1 Outlier on MCV Results

MCV
ABOVE
(Entered value)
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 DAY

NORMAL CONTROL 90 +4 UPPER

LIMIT
+2
MCV assigned value = 87
Expected range = 3.0 87
-2 LOWER
84 -4 LIMIT
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 DAY
BELOW
(Entered value)
5526005B

1-4
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Trends
A trend occurs when five or more values show a gradual increase or decrease. Figure 1.2 shows a trend in
hemoglobin (HGB) control results for an abnormal control level

The expected range is 0.4 and is used to define the low and high limits.

Although none of the results are outside the limits, the graph indicates that a problem exists.
Notice the gradual decline in the hemoglobin control results beginning after the sixth day.

Figure 1.2 Trend of Hgb Control Results

HGB
ABOVE
(Entered value)
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 DAY
+1.0

+0.8

+0.6 UPPER
17.5 +0.4 LIMIT
ABNORMAL HIGH CONTROL
+0.2

HGB assigned value = 17.1 17.1

Expected range = 0.4 -0.2
16.7 -0.4
LOWER
-0.6
LIMIT
-0.8
-1.0
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 DAY
BELOW
(Entered value)
5526004B

Because hematology controls are cell-based, some trending in sizing parameters can be expected. As stated in the
Storage and Stability section of the control product insert, The MCV, RDW and/or RDW-SD parameters may trend
up through the products shelf-life. This is inherent to the product and should not be considered an indicator of
product instability. Recovered values for these parameters should remain within the Expected Range.

If an unexpected trend is noticed:

1. Record the information on your corrective action log.
2. Troubleshoot the problem(s) and remedy the situation prior to running patient samples.

1-5
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Shifts
A shift occurs when there is a sudden change in control results from one run or day to the next. A shift does not
always mean that a problem exists. If the system was calibrated or some troubleshooting was performed before
running the control, a shift could occur. Figure 1.3 shows a shift in platelet (PLT) control results for a normal
control level:

The PLT assigned value is 230 and is used as the mid-line.

The expected range is 25 and is used to define the low and high limits.

Notice the sudden change in PLT control results between the seventh and ninth days.

Figure 1.3 Shift in PLT Control Results

PLT
ABOVE
(Entered value)
2 4 6 8 10 12 14 16 18 20 22 24 DAY
+40
+36
+32
+28
UPPER
255 +24
LIMIT
+20
+16
+12
NORMAL CONTROL
+6

PLT assigned value = 230 +4

Expected range = 25 230
-4
-8
-12
-16
-20

205 -24
LOWER
-28 LIMIT
-32
-38
-4
2 4 6 8 10 12 14 16 18 20 22 24 DAY
BELOW
(Entered value) 5526010B

If a shift is noticed:
1. Record the information on your corrective action log.
2. Troubleshoot the problem(s) and remedy the situation prior to running patient samples.

1-6
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Determine if the Control is In or Out

IMPORTANT: Verify the expiration date on the Assay Sheet. Beckman Coulter recommends using the control within
its expiration date.

Follow the guidelines on the Instructions for Use and Table of Expected Results (package insert) to determine if the
control results are in or out.

The values for each control level are listed for each specific instrument. An assigned value is an estimate of the true
value based on repetitive analysis of the control product on multiple instruments.

1-7
Quality Control (QC) Information and Troubleshooting Guide Hematology

1-8
Figure 1.4 Example Table of Expected Results for 4C-ES Cell Control - Normal
Coulter 4C-ES Cell Control
Table of Expected Results --Normal (with Sample Values)
35** Open vial (Days)
78800 LOT
2013-07-15
AcT 8/10* AcT diff* AcT diff 2* * US AcT 8/10* AcT diff* AcT diff 2* * SI1 AcT 8/10* AcT diff* AcT diff 2* * SI2 AcT 8/10* AcT diff* AcT diff 2* * SI3 AcT 8/10* AcT diff* AcT diff 2* * SI4 Parameters
9.3 9.3 9.3 0.7 x103/L 9.3 9.3 9.3 0.7 x109/L 9.3 9.3 9.3 0.7 x109/L 9.3 9.3 9.3 0.7 x103/L 9.3 9.3 9.3 0.7 x109/L WBC
4.21 4.19 4.13 0.25 x106/L 4.21 4.19 4.13 0.25 x1012/L 4.21 4.19 4.13 0.25 x1012/L 4.21 4.19 4.13 0.25 x106/L 4.21 4.19 4.13 0.25 x1012/L RBC
12.4 12.5 12.3 0.9 g/dL 124 125 123 9 g/L 124 125 123 9 g/L 12.4 12.5 12.3 0.9 g/dL 7.7 7.8 7.6 0.6 mmol/L Hgb
35.7 35.6 35.1 3 % 0.357 0.356 0.351 0.03 L/L 0.357 0.356 0.351 0.03 L/L 0.357 0.356 0.351 0.03 L/L 0.357 0.356 0.351 0.03 L/L Hct
84.8 85 85 4.5 fL 84.8 85 85 4.5 fL 84.8 85 85 4.5 fL 84.8 85 85 4.5 fL 84.8 85 85 4.5 fL MCV
29.5 29.8 29.8 3.3 pg 29.5 29.8 29.8 3.3 pg 29.5 29.8 29.8 3.3 pg 29.5 29.8 29.8 3.3 pg 1.83 1.85 1.85 0.2 fmol MCH
34.7 35.1 35 3.7 g/dL 347 351 350 37 g/L 347 351 350 37 g/L 34.7 35.1 35 3.7 g/dL 21.5 21.8 21.7 2.3 mmol/L MCHC
14.5 14.5 1.5 % 14.5 14.5 1.5 % 14.5 14.5 1.5 % 14.5 14.5 1.5 % 14.5 14.5 1.5 % RDW
212 212 212 40 x103/L 212 212 212 40 x109/L 212 212 212 40 x109/L 212 212 212 40 x103/L 212 212 212 40 x109/L Plt
10.8 10.4 2 fL 10.8 10.4 2 fL 10.8 10.4 2 fL 10.8 10.4 2 fL 10.8 10.4 2 fL MPV
0.229 0.22 0.07 % 0.229 0.22 0.07 % 0.229 0.22 0.07 % 0.229 0.22 0.07 % 0.229 0.22 0.07 % Plt
13.3 13.3 2 ratio 13.3 13.3 2 ratio 13.3 13.3 2 ratio 13.3 13.3 2 ratio 13.3 13.3 2 ratio PDW
32.9 43.6 43.9 5 % 32.9 43.6 43.9 5 % 0.329 0.436 0.439 0.05 ratio 32.9 43.6 43.9 5 % 32.9 43.6 43.9 5 % LY%
13.4 13.1 4 % 13.4 13.1 4 % 0.134 0.131 0.04 ratio 13.4 13.1 4 % 13.4 13.1 4 % MO%
43 43 6 % 43 43 6 % 0.43 0.43 0.06 ratio 43 43 6 % 43 43 6 % GR%
3.1 4.1 4.1 0.8 x103/L 3.1 4.1 4.1 0.8 x109/L 3.1 4.1 4.1 0.8 x109/L 3.1 4.1 4.1 0.8 x103/L 3.1 4.1 4.1 0.8 x109/L LY#
1.2 1.2 0.5 x103/L 1.2 1.2 0.5 x109/L 1.2 1.2 0.5 x109/L 1.2 1.2 0.5 x103/L 1.2 1.2 0.5 x109/L MO#
4 4 0.9 x103/L 4 4 0.9 x109/L 4 4 0.9 x109/L 4 4 0.9 x103/L 4 4 0.9 x109/L GR#
*Applicable only for parameters measured by the instrument.
**Assumes that the Instruction Section of the package insert is performed a maximum of 20 times within 35 days.
SECTION 1: QC CONCEPTS
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Control In or Out
Use Figure 1.4 to practice determining if the results printed by your instrument are within the control value
parameters for the control level that you analyzed on your instrument.

Assuming you ran the Normal control on your instrument:

1. Find the WBC assigned value for the Normal control.
(Answer: 9.3)
2. F ind the WBC expected range.
(Answer: The expected range is 8.6 to 10.0 whereby 8.6 is seven-tenths (0.7) less than the assigned value of
9.3, and 10.0 is seven-tenths (0.7) greater than the assigned value of 8.7.)
3. If your instrument printed WBC results of:
9 .2, is the control in or out?
(Answer: The control is in because 9.2 falls within the range of 8.6 to 10.0.)

1 0.7, is the control in or out?

(Answer: The control is out because 10.7 falls outside the range of 8.6 to 10.0.)

What to Do if the Control is In

If the control is in, run the remaining levels of control before starting patient samples. After running all control
levels and determining that the instrument is performing as expected, then the patient samples can be analyzed.

What to Do if the Control is Out

If the control is out, DO NOT run any patient samples until determining what caused the control to be out, and
solve the irregularity. Beckman Coulter recommends following your laboratorys protocol. After troubleshooting,
record the corrective action in the comments section of your control files, or in a correction action log sheet.

To record a Corrective Action, enter:

1. The date of the occurrence.
2. The condition (such as: WBC low on 4C PLUS Normal).
3. The lot number and expiration date.
5. The action performed, such as repeated-back in range.
6. The initials of the person who performed the corrective action.

Troubleshoot the control out condition according to your laboratorys protocol and to the Table of Expected Results
for the specific control, the instruments IFU and the control IFU.

1-9
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Calibration
Calibration is the process used to adjust the accuracy of the instrument being used. It requires the use of a
calibrator, such as COULTER S-CAL. Calibration is an essential part of the hematology laboratorys quality assurance
program. Before performing a calibration, know what to expect as an outcome.

A calibrator is a substance traceable to a reference preparation or material, used to verify or adjust a measurement.
The College of American Pathologists checklist states that acceptable calibration techniques include: The use of
multiple analyzed whole blood specimens, and the use of a manufactured, certified, stabilized preparation of red
cells, white cells (or white cell surrogates) and platelets (platelet surrogates).

The checklist continues: All calibration techniques should include periodic verifications of analyzer hemoglobin
measurements against a certified hemoglobin preparation (ICSH/WHO International haemoglobin cyanide standard)
or material that has been certified by its manufacturer as being derived from the certified international hemoglobin
cyanide standard using reference procedures.

Consider changes that are appropriate, although not mandatory. There are times when minor calibration changes
may improve control recovery and XB batch mean recovery. Do not accept changes to cal factors that are not
logical. For example, if:

Control recovery values are already low but the calibration data indicates an adjustment to lower levels

Control recovery values are high but the calibration data indicates an adjustment to higher levels

The product was compromised during shipping

For optimal performance, Beckman Coulter recommends assessing and verifying calibration periodically.
The calibration values on the kit Table of Expected Results are traceable to reference methods detailed on the
product insert.

1-10
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Determining if Calibration is Required

Control graphs can help determine if calibration is required. Figure 1.5 shows the graphs of all three levels of control
for the RBC parameter.

Figure 1.5 Three control levels for RBC

RBC
ABOVE
(Entered value)
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 DAY
+?.??
+?.??
+?.??
+?.??
NORMAL CONTROL 4.28
-?.??
-?.??
-?.??
-?.??
-?.??

+?.??
+?.??
+?.??
+?.??
+?.??

ABNORMAL LOW CONTROL 2.46

-?.??
-?.??
-?.??
-?.??
-?.??

+?.??
+?.??
+?.??
+?.??

ABNORMAL HIGH CONTROL +?.??

5.18
-?.??
-?.??
-?.??
-?.??
-?.??
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 DAY
BELOW
(Entered value)

All three graphs show the same issue. The instrument is providing precise (reproducible) results; however, the
results are not as accurate as they could be. The results for each control are on the low side of the assigned
valuesa shift away from assigned mean. If there are no instrument problems, and a pattern is detected in the
graphs, as shown above, it may be necessary to calibrate (adjust the accuracy) of the instrument.

1-11
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Calibration Procedure
Refer to the calibrators product insert, instruments IFU or Special Procedures and Troubleshooting manual for
detailed procedures.

After calibrating the instrument, you may see a shift in the control results. Calibration is a normal cause for a shift.
Figure 1.6 shows how the normal control graph for the RBC parameter, as previously illustrated in Figure 1.5.
Three control levels for RBC, might look if you calibrated the instrument on day 20. Notice the shift in results
as they moved closer to the assigned value of 4.28.

Figure 1.6 Calibration on Day 20 for RBC Normal Control

RBC
ABOVE
(Entered value)
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 DAY
+?.??

+?.??
+?.??
+?.??
+?.??
+?.??
+?.??
+?.??
+?.??

+?.??
+?.??

+?.??
+?.??
+?.??
+?.??

4.28
+?.??
+?.??

+?.??
+?.??
+?.??
+?.??
+?.??

1-12
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

XB Analysis
XB Analysis is a cost effective quality control method that allows for continuous monitoring of system performance
using patient samples in conjunction with commercial controls.

X = Mean

B = Bull (for Brian S. Bull, M.D.)

XB evaluates RBC indices which are typically stable for an individual patient, from day to day, and stable for patient
population over time. The labs assayed commercial control is the final indicator to determine if the analyzer is in or
out of control.

The use of XB check should be considered as added support to a labs QC program, and can be very effective if
a lab has a volume of >100 samples/day. Once established, the target values for XB will be as static unless the
actual patient population changes. Changes to XB with no supporting change to QC might indicate a need to
update targets.

As a Weighted Moving Average, XB uses small batches of 20 samples to calculate each mean. The mean of each
batch is used to compare to the target values. Each laboratory establishes their target values for each MCV, MCH
and MCHC. The target default values according to Dr. Bulls targets, are based on general population across the
nation: MCV = 89.5, MCH = 30.5, and MCHC = 34.0.

XB Value is Out of Range

If the XB value is out of range, check:

which directly measured parameters are most affected

if the change is sudden or ongoing

batch contained samples from particular population (renal, oncology)

Refer to Using XB for Troubleshooting Specific Cases.

XM Analysis
XM Analysis is available on the DxH 800/DxH 600 and LH 780 instruments. This is a quality-control method that
uses an Exponentially Weighted Moving Average (EWMA) of CBC, Diff, NRBC and Reticulocyte parameters and
compares them with known target values, to monitor instrument performance. For more information, refer to the
specific instruments IFU manual. For the DxH 800/DxH 600, refer to the chapter titled Set Up XM Control, and for
the LH 780, refer to the chapter titled XM Analysis.

Inter-laboratory Quality Assurance Program (IQAP)

A program administered by Beckman Coulter, Inc. for users of its hematology instruments and controls. It
allows a laboratory to compare its performance to all other laboratories in the program that use the same or
similar instrument category and control products.

1-13
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Recording Control Results

Beckman Coulter strongly recommends that if your laboratory is not benefiting from automatic storage of control
results, then use the Daily Data application found in the Electronic Interlaboratory Quality Assurance Program
(eIQAP).

Control Summary Data

Control Summary Data should be submitted to IQAP as soon as possible. This allows the IQAP Department to issue
an updated report more frequently, and be able to troubleshoot any response time irregularity, in case there is an
instrument issue.

It is necessary to submit the minimum number of ten (10) runs; 16 runs provide statistical validity when
submitting data to IQAP. If the report reflects less than 10 data points, it will not be included in the peer
comparison pool, and will not receive SDI and CVI comparisons.
If there is a limited number of participating laboratories (less than 10 participants), laboratories should
evaluate peer group performance.

If submitting data via the Reagent Management Card (RMC) or external media, ensure that any data which
has already been submitted, even if it is the same lot number, has been deleted and is not included.

If submitting data via the RMC, ensure that only current lots of control data are stored on the card. The IQAP
Department cannot separate the old data stored in the card from the new data.

IQAP reports are cumulative for the same lot of controls.

NOTE

D
 xH 800/DxH 600 - the QC files can be submitted as data accumulates. Data can also be submitted daily until
the control expires.

A cT Diff - DO NOT enter data manually twice. This will generate a flag for the report and the results will not be
accurate.

Other Controls for the Hematology Laboratory

The College of American Pathologists states that quality control procedures for hematology processes may include:

The use of preserved or stabilized whole-blood controls

Retained patient specimens

Moving average monitoring of red cell indices

Some combination of the above

There are two main ways that labs use patient blood as controls:

Replicate testing of pooled or designated patient blood at specified times during the day

Continual moving average calculations on routine patient samples XB or XM. XB is automated in Beckman
Coulter instruments with data management and workstations.

1-14
SECTION 1: QC CONCEPTS Quality Control (QC) Information and Troubleshooting Guide Hematology

Studies (Bull 1974, Koepke 1981) indicate that the red cell indices (MCV, MCH, and MCHC) of patient populations
are stable over time. This stability characteristic of the indices is the basis for XB analysis. XB is helpful to compare
performance of patients across instrument systems.

Mean values established from a large portion of the patient population are used as reference. Subsequent moving
averages from the indices of smaller batches of patient samples are compared with these target values. Significant
changes (more than 3%) can indicate a change in system performance.

Delta Checks
Delta checking can also be used as a quality control method. It is a means of checking to see if certain parameters
are within a user-defined range when the parameter results of two samples from the same patient are compared.
Some Beckman Coulter instruments perform delta checks automatically.

Preventive Maintenance
Refer to your instrument manual to determine which, if any, preventive maintenance procedures are required for
your instrument. Most Beckman Coulter instruments do not require routine preventive maintenance, but there are
cleaning and replacement procedures available for troubleshooting purposes.

Maintaining a Log
It is essential that you maintain a log documenting your instruments use. This will assist you both in the laboratory
routine and when you need service. Use your log book and your instrument certification documents to keep your
systems history current.

Technologist Review
An experienced medical technologist who reviews the data from an instrument can detect possible malfunctions
or irregularities. Technologist review includes assessing the reasonableness of results, investigating questionable
cases, knowing when to repeat an analysis, knowing how to interpret QC results, knowing how to interpret
calibration recommendations, and when there is a problem, knowing how to define and solve it. These are important
skills necessary for any QC program.

1-15
SECTION 2

Troubleshooting
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology

Troubleshooting Overview
This section provides information on how to troubleshoot common quality control issues, as well as specific issues
related to XB. Irregularities could be detected by means of observation, history/event log entries, calibration or
control failures, unexpected patient results, or system error messages.

If unable to solve the irregularity, contact your lab administrator or your Beckman Coulter representative.

Troubleshooting Guidelines
Always look at the whole picture and obtain as much information as possible prior to determining the most suitable
method for the investigation. Use the following checklist to assist tracking your investigation.

Table 2.1 Troubleshooting Checklist

Investigation Yes No Comments
What is unique to the case?
new reagent
new control
new calibrator
recent part replacement
maintenance recently performed
h aving failures on controls or patient
samples and controls
What is common to the situation?
more than one parameter affected
affected parameter is directly measured
WBC
RBC
Hgb
MCV
PLT
MPV
Diff%
Retic%
related parameters
analysis method for each parameter
multiple levels of control material affected
problem occurring on multiple instruments
change of laboratory environment within range

2-1
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology

Investigation Yes No Comments

laboratory temperature
humidity
storage conditions
other
reagent shipment
irregularities in packaging
reagents stored according to package insert
calibrators stored according to package insert
controls stored according to package insert
receiving error messages (refer to the IFU)
flags
codes
QC target ranges (appropriate/correct)
package insert (appropriate/correct)
table of expected results (appropriate/correct)
any recent manufacturers notification(s)
Have the control samples been checked?
new lot(s) of control
proper analysis of correct samples
controls exceed
open/closed vial expiration dates
claims
controls stored properly
controls mixed properly
control properly presented
c ontrol failures become apparent after
recent calibration
c ontrol failures after service
Has the reagent(s) been checked?
correct reagent(s)
reagent(s) loaded and connected correctly
new reagent(s) lot number
reagent(s) stored properly
reagent(s) properly prepared
reagent(s) expired
reagent(s) exceed the open/closed
container stability 2-2
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology

Investigation Yes No Comments

Has the calibration been checked?
date of last calibration
lot number and expiration date of calibrator
correct calibration information been entered
calibrator stored, prepared and properly analyzed
any parameter adjustment
WBC
RBC
Hgb
MCV
PLT
MPV
calibrator expired
calibrator used past open vial stability claims
control failures post-calibration
a greement between the control recovery
post-calibration and the change(s) made
during calibration
w
 aited for the next lot of controls to determine
need for adjustment
IQAP Checks
Evaluate IQAP statistical data by parameter for each
level of control including:
Mean(s), SD, SE diff
Current and historic CVs
SDI (accuracy vs. pool)
CVI (precision vs. pool)
IPI (overall accuracy and precision vs. pool)
a ny indication of similar recovery from the
peer group in IQAP for the same lot
a ny indication of similar recovery from the
peer group in IQAP for the same parameters

2-3
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology

Investigation Yes No Comments

Has the instrument hardware been checked?
date and reason for last service
maintenance performed correctly and up-to-date
Carryover within specs
Precision (repeatability) within specs
cleaning reagents freshly prepared and installed
m
 aintenance reagents freshly prepared
and installed
visual inspection of hardware, check for:
leaks
build up
disconnected tubing
bent probes
worn-out components
How does the control recovery for this system
compare with:
XB
XM
extended QC
survey material results

To assist in determining corrective actions based on your conclusions, refer to Figure 2.1.

2-4
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology

Figure 2.1 Corrective Action Flowchart

 Verify:
Correct control level, lot number & expiration date
Quality Control
are in use (table of expected results)
Troubleshooting
Control material in use is not hemolyzed, in-use beyond
open vial dating or compromised due to shipping or storage

Proper storage, mixing and processing of control

Control Current control recovery is in line with IQAP pool recovery

Open new vial of control and rerun

If available, try a new lot of control

Correct reagent(s) in-use; lot #s, closed and open container

expiration dates & storage conditions
Reagents
Daily checks, background counts are within limits

Open and prime new reagents as necessary; rerun controls

Date of last calibration; calibrator used for calibration was

within expiration dating
Calibration Cal factors have not changed
Similar control recovery for the parameter(s) in
question for all levels of control; system demonstrates
repeatability and carryover within specifications;
consider calibration / verification

Cleaning and/or maintenance was properly performed

Instrument
Hardware No recent service / major component replacement(s)

Visual inspection confirms no leaks, disconnected

tubing or damaged parts, etc.

Laboratory Instrument and laboratory temperature, humidity

Environment within limits; no errors or codes

2-5
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology

Using XB for Troubleshooting Specific Cases

XB(bar above X) analysis is an automated quality control technique comparing the RBC indices obtained from patient
samples to established target values. This analysis provides valuable data on the RBC parameters. When XB batch
means exceed the target values it is necessary to determine if there was a change in the patient population or an
instrument problem. Using the information in this section identification of the causes for the change in batch mean
values can be determined. Determining which directly measured parameter(s) are associated with the RBC indice in
question will aid in troubleshooting an instrument problem.

It is necessary to determine any population changes:

which parameter is out of range

how is the parameter or indices are derived

MCV - derived from RBC histogram
MCH = Hgb x 10/RBC
MCHC = Hgb x 100 /Hct
HCT = RBC x MCV/10 (HCT=RBC X MCV/10)

RBC indices tell us about the three (3) directly measured parameters:
RBC
HGB
MCV

Table 2.2 identifies the directly measured parameter (X axis) and the change to the RBC indice (Y axis)
MCV Low MCV High MCH Low MCH High MCHC Low MCHC High
MCV Decrease Increase ---- ---- Increase Decrease
RBC ---- ---- Increase Decrease Increase Decrease
HGB ---- ---- Decrease Increase Decrease Increase
Hct Decrease Increase ---- ---- Increase Decrease

Table 2.3 Using XB for Troubleshooting Specific Cases

Cases Action
Batch mean is skewed by the inclusion of diluted Turn off XB for repeated abnormals or dilutions. If pos-
samples, or the results are repeats of same sible, exclude the samples. If unable to delete or turn off
abnormal patient. XB, reestablish a more meaningful XB target.
Change in patient population because one or more XB targets should be re-established to reflect current
types of patients are added or removed from the mix of population or the XB should be turned off when these
patient population (neonatal group was added, patients are processed.
or dialysis samples).
Instrument may need cleaning or maintenance service.
Calibration drift (except MCV and MPV) exhibited by XB
Ensure service status is OK before attempting
and controls.
calibration.
Sudden change in: Instrument may need cleaning or maintenance service.
component failure Ensure service status is OK before attempting
the cal factor during routine recalibration calibration.

2-6
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology

Glossary
This glossary is a collection of specialized terms and their meanings that are either used in this document or related
to the information in it. If a term has more than one meaning, all meanings relevant to this manual are included.

Accuracy
The ability of the instrument to agree with a predetermined reference (true) value; closeness of agreement between
a measured quantity value and a true quantity value of a measurement; closeness of agreement between a
measurement result and the accepted reference value.

The closeness of a result to the true (accepted) value (hitting the bulls eye). In IQAP, the peer group (pool)
represents truth. Refer to SDI.

Assay
A procedure of repeat testing to determine the assigned value for a given control lot.

Bias
Control values demonstrate a consistent recovery above or below the assigned value.

Calibration
The procedure used to set an instrument at a specific value or values using a reference method.

Calibrator
A substance traceable to a reference method, preparation, or material used to calibrate or adjust a measurement.
COULTER S-CAL calibrator is an example.

Carryover
The amount, in percent, of sample remaining in the system and picked up by the next sample cycled. Low-to-high
carryover is the amount of sample with low cell concentrations carried over to samples with high cell concentration,
such as diluent to blood. High-to-low carryover is the amount of samples with high cell concentrations carried over
to samples with low cell concentrations, such as blood to diluent.

Carryover is performed to determine if one sample interferes with the analysis of the next sample. Ideally, carryover
is negligible.

Coefficient of Variation (CV)

The reproducibility of your results expressed as a percentage. It describes variation around a mean and is calculated
as a ratio between standard deviation and the mean.

CV% = SD x 100
Mean

CVI = Your Lab CV

Pool CV

x
X= 1
N 2-7
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology

SD x 100
Coefficient of Variation Index (CVI) CV% =
Mean
Indicates how your precision compares to that of your peers. It is expressed in units as a ratio of your CV divided by
the pool CV. Plotted on the Instrument Performance Matrix, the CVI is a visual indicator of overall precision for the
data set.

CVI = Your Lab CV

Pool CV

Control
A substance used in routine practice for monitoring
x1 the performance of an analytical process or instrument.
X=
N
By comparing your instrument control results against the assigned value (assay value), you can monitor your
instruments accuracy and precision. The assigned value is determined by repeatedly testing the control material
on many instruments, and then determine a close
(x estimate
x)2 of the true value. This process is known as assaying.
SD = an average of all the results using the prepared sample (control). The
When assaying is complete, we can obtain
N1
determined value is called an assigned value.

Beckman Coulters cell controls are designed specifically for each type of instrument.
SDI = Your Lab Mean Pool Mean
Delta check SE diff
A check on sample results that is made by clinical laboratories to determine if the current result on a particular
patient is within certain limits when compared to the last result obtained on that same patient.
SE DIFF = (Pool SD)2 + (Lab SD)2

Electronic IQAP (eIQAP)

The web based version of IQAP providing the fastest turn-around-time for reports, simplified data
submission and administrator and user controls and corporate reports. To access Electronic IQAP, go to
www.beckmancoulter.com/qap/index.jsp. eIQAP is available to registered IQAP participants using your
existing IQAP participant number.

Inter-laboratory Quality Assurance Program (IQAP)

A program administered by Beckman Coulter, Inc. for users of its hematology instruments and controls. It allows
a laboratory to compare its performance to all other laboratories in the program that use the same or similar
instrument category and control products.

Instructions for Use (IFU, package inserts)

IFU and package inserts are included with any Beckman Coulter hematology or flow cytometry products. The
package insert contains specific information pertaining to the batch or lot of controls from which your control
product was manufactured. The assigned values are listed on a Table of Expected Results that is included within the
cell control kit. The Table of Expected Results is specific to the batch or lot of controls.

Instrument Performance Index (IPI)

IPI is a single point that represents both the precision and accuracy of your system as compared to that of your
peers. This point is plotted on the Instrument Performance Matrix for each parameter and level. Refer to Standard
Deviation Index (SDI) and Coefficient of Variation Index (CVI) for further details.

2-8
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology
CV% = SD x 100
Mean

Levey-Jennings Graph
A tool for graphing daily control results to visually detect shifts or trends. Refer to Shift and Trend for further details.
CVI = Your Lab CV
Mean Pool CV
Mathematical average for a group of data points.

x
X= 1
N
Outliers
Outliers are results that fall outside the low/high limits for any parameter.
(x x) 2
SD =
N1
A value usually so far separated from the other values that it suggests that it may be from a different population, or
the result of an error in measurement.

Pool
SDI = Your Lab Mean Pool Mean
SE excluding
The heart of peer review. It is the average of all participant means diff your laboratory data that use the same
control lot and similar instrument systems. The pool is the standard against which individual laboratory results are
compared.
SE DIFF = (Pool SD)2 + (Lab SD)2
Pool Variance
The squared standard deviation of the means of all the other labs.

Precision (Reproducibility or Repeatability)

Precision of a given measurement procedure is subdivided according to the specified precision conditions.
Repeatability relates to essentially unchanged conditions and is often termed within-series precision or within-
run precision. Reproducibility relates to change in conditions, i.e.: different laboratories, operators, and measuring
systems (including different calibrations and reagent batches) and is often termed interlaboratory precision.

The closeness of successive test results on the same sample. Refer to Accuracy for further details.

Quality Control (QC)

In laboratory testing, quality control is the assurance that results are reported correctly (accuractely) and that
subsequent results do not change significantly unless the patients condition changes (precision).

Repeatability
The closeness of agreement between the results of successive measurements of the same substance carried out
under the same conditions of measurement. Also known as reproducibility, precision, within-run precision, within-
assay, within-run, intra-assay, and intra-run precision.

Shift
On a Levey-Jennings graph, a shift is indicated by an abrupt change in the pattern of data points to a higher or lower
level, or a sudden change in results from one day to the next.

2-9
 CV% = x 100
Mean
CVI = Your Lab CV
SECTION 2: TROUBLESHOOTING Pool CV Quality Control (QC) Information and Troubleshooting Guide Hematology

CV% = SD x 100
CVI = Your Lab
Mean CV
Standard Deviation (SD) Pool CVx1
X=
N measured. A 2SD is an accepted laboratory standard; 95% of
Variation around the mean expressed in units being
all results in a normal population should fall within two standard deviations of the mean.
x1= Your Lab CV
X = CVI
N Pool (x
CV x)2
SD =
N1
Standard Deviation Index (SDI)
(xx1 x)2
Indicates how well your meanSD =X = with the peer group mean for a given parameter and level of control. It is
compares
NN 1 in means to the standard error of the differences (SE diff). Plotted on
expressed in units as a ratio of the difference
the Instrument Performance Matrix, the SDI SDIis=a Your Lab Mean Pool Mean
visual indicator of overall accuracy for the data set.
SE diff
(x x)2
SD =
SDI = Your Lab
N Mean
1 Pool Mean
SE DIFF = diff SD) + (Lab SD)
SE(Pool
2 2

SDI= diff)
SE DIFF = (SE
Standard Error of the Differences (Pool
YourSD)
Lab +Mean
(Lab SD)
2
Pool Mean2

SE diff
The denominator in the SDI formula calculated as the square root of your lab variance plus the pool variance.

SE DIFF = (Pool SD)2 + (Lab SD)2

2-10
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology

Trend
A trend is a gradual change in direction of the data points. A trend is identified when, on repeated analysis, results
form an increasing or decreasing pattern away from the established mean.

A trend occurs when five or more control values show a gradual increase or decrease.

ABOVE WBC
(Entered value)
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 DAY
+2.0
+1.8
+1.6
+1.4
+1.2
+1.0
+0.8
+0.6
+0.4
+0.2
ASSAY
VALUE
-0.2
-0.4
-0.6
-0.8
-1.0
-1.2
-1.4
-1.6
-1.8
-2.0
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 DAY
BELOW
(Entered value)

XB Method
A hematology quality control technique using routine patient blood analyses in a weighted moving average
algorithm. XB analyses are performed automatically by many Beckman Coulter instruments.

Your Lab Variance

The squared standard deviation of your individual data points.

2-11
SECTION 2: TROUBLESHOOTING Quality Control (QC) Information and Troubleshooting Guide Hematology

References
A Method for the Independent Assessment of the Accuracy of Hematology Whole-Blood Calibrators, 1992, B. Bull, A.
Richardson-Jones, M. Gibson and D. Twedt, Am. J. Clin. Pathol., 98, 623-629.

Advances in Hematological Methods: 1982. O.W. van Assendelft and J.M. England, eds. CRC Press: Boca Raton, FL.

Barnett R.N.: 1979. Clinical Laboratory Statistics. Little, Brown and Co.: Boston.

Basic Concepts of QC: 1986. Coulter Electronics, Inc., Hialeah, Florida (Coulter PN 4235526).

Biometry: 1995. Robert R. Sokel and F. James Rohlf, eds. W.H. Freeman and Company: New York.

Bull B.S. and Korpman R.E.: 1982. Intralaboratory Quality Control Using Patient Data. In Methods in Hematology
Quality Control, I. Cavill (ed). Churchill Livingston: New York.

College of American Pathologists: 2012 CAP Checklist. Skokie, IL.

Concepts of XB Analysis - A Programmed text: 1985. Coulter Electronics, Inc: Hialeah, Florida (Coulter PN 4235294).

First International Conference on Advances in Clinical Haematology: Current Practice and Future Directions for
Quality Assessment in Laboratory Haematology, 1990. J.A. Koepke and J.M. England eds. Clinical and Laboratory
Haematology, Vol 12, Suppl.1, 1990.

Gilmer P.R. and Williams L.J.: 1980. Status of Methods of Calibration in hematology. Am J Clin Path 74(4):600.

Interlaboratory Quality Assurance Program, F.C. Anderson, Clin. Lab. Haemat. 1190, 12, Suppl.1, 111-116.

Introductory Statistics: 1999. Neil A. Weiss - Arizona State University, eds. Addison-Wesley, Inc.: Massachusetts.

Koepke J.A.: 1984. Laboratory Hematology. London: Churchill Livingston.

Koepke J.A. and Protextor T.J.: 1981. Quality Assurance for Multichannel Hematology Instruments. Four years
experience with patient mean erythrocyte indices. Am J Clin Path 75(1):28.

Laboratory Quality Assurance: 1987. P.J. Howanitz and J.H. Howanitz, eds. McGraw-Hill: New York.

Levey S. and Jennings E.R.: 1950. The use of control charts in the clinical laboratory. Am J Clin Path 20:1059.

Oxford BS: 1985. Statistical Methods in Quality Assurance Software. J Med Tech 2:629.

Performance Goals for the Internal Quality Control of Multichannel Hematology Analyzers, Proposed Standard
NCCLS H26-P, Vol 9, No. 9, 1989.

Quality Assurance in Haematology, 1988. S.M. Lewis and R.L. Reference-2 A62451AA

Quality Control in Haematology, Symposium of the International Committee for Standardization in Haematology,
1975. S.M. Lewis and J. Coster eds. AP Press, ISBN 0-12-446850-0, LONDON.

Quality Control of Automated Cellular Analyses - The Fallibility of Embalmed Blood, 1985, J.M. Gibson, Blood Cells,
11, 301-307.

S-CAL Calibrator: 1985. Hematology Analyzer Vol. 4 No.3. Coulter Electronics, Inc.: Hialeah, FL.

Stewart C.E.: 1985. The Choice of Control Material: Important factors. J Med Tech 2:634. Verwilghen eds. Bailliere
Tindall Press, ISBN. 0-7020-1322-6, LONDON.

2-12
MG-18239A Beckman Coulter, the stylized logo, Coulter and DxH are trademarks of Beckman Coulter, Inc.,
and are registered with the USPTO. AcT and AcT diff are trademarks of Beckman Coulter, Inc.