الفهرس Only 14 pages are availabe for public view
 |  | from | 227 |  |  |
| | | from | 227 | | |
Abstract
Decisions about diagnosis, prognosis and treatment are based on the results and interpretations of lab tests, and irreversible harm may be caused by erroneous results.
To achieve good laboratory quality; the lab is required to have a comprehensive quality program to establish qualified and experienced staff, well controlled pre-analytical phase, calibrated and maintained equipment, standardized methods, adequate quality control, and lastly accurate recording and reporting in a safe environment under the umbrella of sound laboratory management process.
Providing the best patient care requires laboratorians to strive for the highest performance. Accreditation allows laboratories to regularly evaluate their performance, their compliance with the requirements of the accrediting association, and their ability to improve the accuracy of the patients’ results they provide. Accreditation is one of the keys to improve laboratory services. Self-assessment is an important step prior to accreditation as it gives a clear indication of where the laboratory is standing in this long way of accreditation.
Our study aimed at evaluating the quality of work, in the clinical hematology and immunology units; Clinical Pathology Department; Alexandria Main University Hospital as regards the pre-analytical, analytical, post-analytical phases of testing together with evaluating laboratory safety, resource and staff management together with laboratory managerial process. This evaluation was performed using inspection sheets that were designed according to the CAP, ISO 15189 and JCI recommendations.
Following evaluation, a gap was found to exist where the existing policies, processes or procedures did not fully meet the stated requirements. Laboratory management first established a steering group (committee) that included representatives from each laboratory discipline. Every effort was made to analyze this gap; the working group itemized the defective requirements and started to work on narrowing this gap.
At the beginning of the study, the pre-analytical phase was recognized as the most defective phase throughout the total testing process in the clinical immunology and hematology units. This was in agreement with many published studies showing a high frequency of the pre-analytical errors. Laboratory safety was the most defective of the assessment activities used.
During the study, the so called ”manual of laboratory service” a Pre-analytical quality manual, was formulated, the request form was standardized in agreement with the CAP recommendations. Also criteria for rejection of unacceptable specimens was formulated and applied within the pre-analytical manual.
As a step forward for the documentation of all the analytical procedures; a procedure manual describing all routine tests was formulated. QC performed and documented perfectly and regularly, comparability of results of those examinations performed using different procedures or equipments was developed. The clinical hematology and immunology units will be enrolled in a PT program in order to regularly evaluate our performance. The analytical phase was the most easily controllable and standardized phase throughout the whole testing process.