EQA LOGO

EQUITY AFIA LABORATORIES PROCEDURE MANUAL

Name Position Signature Date

Authorized &
issued by:

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Acknowledgement:

Today’s healthcare environment requires institutions that provide the highest level of quality and ensure
patient safety but Kenya has an overwhelmingly young population, which faces various disparities in
demographic determinants of health. Levels of public expenditure are insufficient to link the general
population to quality preventive and curative care and to counter Kenya’s disease burden.

Thus Equity Afia was proposed as a sustainable integrated health model to ensure improvement,
increased access to and utilization of quality and standardized health care, improved health education and
affordable and comprehensive private health insurance for Kenyans. It has developed standardized, high-
quality health care services using a high-volume, low-margin model.

The Equity Afia policies and procedures’ manuals have been developed to assist new and existing staff to
provide standardized and high quality healthcare.
The Equity Afia consultants have developed these manuals with the goal of providing the medical
professionals with the guidance needed to function with skill and confidence in their roles. In addition,
these manuals provide several helpful links for resources that the staff may need to complete their
responsibilities.

Equity Afia Management team wishes to acknowledge and thank all of the contributors and authors of
these documents. These individuals spent countless hours over the past year and some six months writing,
proofing, re-writing, organizing and formatting these manuals. The authors and contributors include Dr.
Gabriel Njue (Chief Clinical Manager) who authored the nine clinical guidelines manuals pharmacy
manual and formulary; Linner C. Kosgey (Chief Nursing manager) who authored the nursing manual;
Ruth N. Kimuhu (Chief Laboratory manager) who authored the laboratory manual and handbook; Joakim
Kimani (Information and analytics manager) who authored the IT manual and Alice K. Osiemo (Program
coordinator) who authored the human resource manual. I also wish to acknowledge and appreciate Dr.
Bola Tafawa for her vision of the Equity Afia project. She had the foresight to dream that such a health
model can exist and be implemented in a sustainable way. Together with Dr. Njue, she recommended that
such manuals need to be developed and supported writing and review of the documents.

Disclaimer:
The information presented in these manuals represents the individual authors’ opinions and experiences
as medical, public health and IT professionals. Each section has been thoroughly researched by the
authors and individual members of the Equity Afia consultant team and is meant to provide a broad range
of helpful guidance to new and existing Equity Afia facility staff.

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Introduction
Equity Afia Health Facilities have developed and established a Quality Management System
(QMS) based on ISO 15189: 2007, a medical laboratory specific standard.
The QMS has set standards for requisition, patient identification and preparation, sample
collection, transportation, storage, processing, validation and interpretation of patient test results.

The QMS is laid out in three manuals, the quality manual, Standard operating procedures (SOP)
manual and laboratory handbook.

The purpose of this SOP manual is to assist the medical staff at Equity Afia Health facilities’
Laboratories in complying with high quality processes in sample collection, processing, resulting
and maintaining the QMS. It shall also form the primary reference and training manual for new
and existing staff.

We trust that this information will prove to be a valuable resource. We shall keep you
informed on any changes and improvements in our procedures.

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 Training Record
The following Equity Afia Laboratory staff have read and understood this Procedure Manual.
They have agreed to contact their Supervisors and Equity Afia Head Office, if they plan to
modify this manual.
I acknowledge that I have read, understood and agree to follow this SOP:
No. Name Signature Date

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 1. SOP review and updating log
Reviewer Name Signature Version Effective
Position Description of change
No. date

EQA LOGO System Procedure SOP No: EQA-LAB-SOP01

Laboratory Department Selection and Evaluation of a Referral Version: 1

Section: General Quality Laboratory Copy No:
Effective Date:
1.1. Purpose/Applicability
1.2. Purpose
To provide instructions to be followed when selecting and evaluating referral
laboratories at Equity Afia Laboratories (EQAL). It also provides an effective
system for referral of samples for testing to referral laboratories to ensure quality of
results generated and maintain TAT.

1.3. Scope
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 This document applies to all staff working for EQAL. This procedure also applies
to the review of contract within EQAL. Review of contract records may either
be in hard copy or in electronic form

1.4. Principle/Safety
1.4.1. Principle
N/A

1.4.2. Safety
1.4.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviation, Definitions and Terms

2.1. Abbreviations
2.1.1. EQA-Equity Afia Health Facility
2.1.2. ISO – International Organization for Standardization
2.1.3. GCLP – Good Clinical Laboratory Practice
2.1.4. SOP – Standard Operating Procedure
2.1.5. EQAL – Equity Afia Laboratory

2.2. Definitions and Terms

N/A

3.0. Sample type, Equipment and Materials/ Reagent/ Supplies

N/A

4.0. Responsibility
4.1. The Laboratory Management Team is responsible for ensuring that this SOP is
implemented as written

5.1. Procedure
5.2. Factors to consider before referring samples to another laboratory
5.2.1. Technical Factors
5.2.1.1. A test will only be done in EQA Laboratories if it can be
done accurately. The ability to provide reliable test results is
limited by the availability of test methods and equipment that EQA
staff is competent to use, and the time to perform the test. If the
test is classified as highly complex, it is probably best to send it to
a professionally operated referral laboratory
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 5.2.1.2. Whether the specimen can be transported to another
laboratory without deterioration in transit
5.2.1.3. Before deciding to have referral testing, EQA might
consider whether an alternative test might provide the same
information. If yes the EQA Laboratory in-charge will be
asked to discuss the issues with the requesting physician(s)
5.2.1.4. The availability of equipment, service and technical trouble
shooting for any new system being considered
5.2.1.5. Another technical consideration is the anticipated
workload.

5.2.2. Legal Considerations

5.2.2.1. Tests that are classified as highly complex by competent
authorities require more qualified staff than other tests. Before
considering performing such tests, be sure that the laboratory will
meet all regulatory requirements local and international competent
authorities
5.2.2.2. Some tests carry a higher exposure to medical malpractice risk
than others. Carefully review any tests that could expose EQA to a
higher level of risk and be sure that the laboratory staff is properly
qualified to perform such testing

5.2.3. Financial Considerations

5.2.3.1. Production of income is not generally the primary
motivating factor but financial factors must be considered. The
daily volume of each test has a direct influence on the cost.
Cost per test must include the cost of reagents for
standardization and quality control, proficiency testing costs,
amortization of equipment, and the cost of personnel and
space for the laboratory. Also consider whether additional
equipment will be necessary for the test and whether there is
adequate space.

5.2.4. Managerial Considerations

5.2.4.1. For tests of moderate complexity, EQA Laboratories require the services
of consultant pathologists who will assist in the choosing of methods and
test systems, set up quality control for the test, review and evaluate
proficiency test results, and troubleshoot problems. Tests classified
as highly complex by CLIA '88 require a supervisory technologist with
in-depth understanding of the tests and the ability to independently
troubleshoot problems with them

5.2.5. Physician and Patient Convenience

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 5.2.5.1. Immediate return of results is important to the physician and patient.
With certain patient populations, there are significant benefits in having
the results available quickly

5.2.6. Compliance
5.2.6.1. EQA will fully comply with all Local rules and regulations when
contracting tests to referral and back-up laboratories. Compliance with
the EQA Contracting Policies is mandatory for all contracts with referral
and back-up laboratories; although exceptions may be made in certain
circumstances where the facts demonstrate that an exception is
appropriate. Such exceptions are discouraged and only permitted where
the applicable legal requirements continue to be met
5.2.6.2. In general, agreements with referral and back-up laboratories must:
5.2.6.2.1. be in writing, signed by the parties and must specify the
services covered;
5.2.6.2.2. specify the timeframe for the arrangement;

5.3. Referral Laboratory Selection

5.3.1. EQA Laboratories use a standardized list of objective questions to select
and evaluate a range of important customer service and technical issues in
a referral laboratory. We ask each referral laboratory for specific
information about TAT, critical values and Stats, problems with lost
specimens, consultation services, quality of results, and courier services.
This checklist enables us to uncover significant problems with bidders and
makes us aware of a facility's innovative, customer-service oriented
solutions to challenging problems. Each quality and service criterion
has been assigned a score we use to compare facilities (see Appendix 2
"Technical evaluation scoring sheet"). These factors constitute 75% of a
lab's total score; cost factors constitute the remaining 25%. Cost becomes
a determining factor when all competitors are relatively equal in quality
5.3.2. Define the service, quality and consultative support needed from a referral
laboratory
5.3.3. Evaluate each prospective referral laboratory's ability to meet these
requirements. Factors that are important in the selection of a laboratory
include the following:
5.3.3.1. Tests offered
5.3.3.2. How specimens are handled and whether assistance is provided
in obtaining and handling them
5.3.3.3. Turnaround time
5.3.3.4. Adequacy and style of reports
5.3.3.5. Availability and quality of consultation services
5.3.3.6. Licensing and accreditation
5.3.3.7. Cost
5.3.3.8. Extra services offered
5.3.3.9. Professional and business reputation
5.3.3.10. Quality and adequacy of personnel
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 5.3.3.11. Quality management activities
5.3.4. Referral Laboratory evaluation checklist will be used to score and choose
the best potential referral laboratories. Each requirement in the checklist
has been assigned points.
5.3.5. Highest consideration will be given to the laboratory receiving the greatest
number of points. However in some circumstances, some factors are so
important that despite a high score, a laboratory lacking one of these may
be eliminated from consideration. For example, a laboratory with a poor
reputation for its business ethics might be eliminated from Clients’
consideration despite a relatively good score in other factors.

5.3.6.Getting the best service from EQAL’s referral Laboratory(ies)

5.3.6.1.EQAL will have good service from its referral laboratory (ies) if both
agree on reasonable expectations, and strive to meet them.
Issues that must be agreed on include:
5.3.6.1.1. Turn-Around-Time (TAT): Usually, the referral laboratory's
Users' Manual indicates the schedule for performing tests, and
the expected turnaround time.
5.3.6.1.2. Users' manual: Referral laboratories usually provide a users'
manual to their clients; the manual's quality and usefulness
can vary. At a minimum, the manual should list:
5.3.6.1.2.1. Specimen requirements, including type of collection
container, amount of specimen, and any special
handling instructions such as protection from light,
removal of blood cells from serum or refrigeration or
freezing
5.3.6.1.2.2. Tests available from the lab
5.3.6.1.2.3. Usual turn-around-time and testing schedule
5.3.6.1.2.4. Cost to the patient
5.3.6.1.2.5. Whom to call if there is a question or problem
5.3.6.1.3. Request forms: Some request forms are easier to use than
others:
5.3.6.1.4. Problem resolution: The Customer Service Representative is
the first line of problem resolution. EQAL staff should
become acquainted with this person and know how to reach
him or her.

5.3.7. Getting Good Service

5.3.7.1. Use the request form properly
5.3.7.1.1. The technical staff will ensure that they complete all requested
information on the form accurately.
5.3.7.2. Reporting
5.3.7.2.1. The referral laboratory's report forms should be easy to read,
and contain appropriate reference ranges.
5.3.7.3. Developing a Relationship

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 5.3.7.3.1. Service will be perceived as more personal if you and EQAL
staff are able to establish a closer relationship with members
of the referral laboratory's staff. Large laboratories may have a
customer service representative who functions as a sales
person, trouble shooter and as a local contact for the
laboratory. Frequently, this person will have a professional
medical laboratory technology background, and can work with
EQAL staff to teach them how to use the referral laboratory
optimally. If there are service problems, this individual is the
first line of problem resolution

5.3.7.4. Professional Consultation

5.3.7.4.1. Consultation is usually available from a consultant
professional at the referral laboratory. Most referral
laboratories are more than happy to advise their users about
test selection, result interpretation for specific patients, test
interferences due to food, drugs or other factors, and to
provide specific protocols for performing complex tests such
as endocrine stimulation tests

5.3.7.5. Specimen Collection and Handling

5.3.7.5.1. These are critical steps in the testing process. Carefully follow
the referral laboratory's instructions about the correct
collection tube or container to use. Compulsive attention to
anticoagulants and preservatives is essential for correct test
results.

5.3.7.6. Communication
5.3.7.6.1. Make EQAL expectations known to the Referral Laboratory
customer service representative or laboratory manager. The
Referral Laboratory Selection Checklist in this chapter can
form the basis for discussion of Clients’ expectation

5.5. Quality Control/Calibration

5.5.1. Quality Officer or designee will do random Quality Control checks to
ensure that this SOP is implemented as written. If Quality control checks
reveal non-compliance to this SOP, the SOP deviations and violations will
be investigated, corrective and preventive action initiated, implemented,
reviewed and closed-out. All corrective and preventive action should be
documented in the corrective action form.

5.6. Results
N/A

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 5.7. Reference values
N/A

5.8. Reporting
N/A

5.9. Limitations
N/A

5.10. Specimen Retention and Storage

N/A

6.0. Related Documents

6.1. Reporting and release of test results (EQA-LAB-SOP39)
6.2. Reporting critical results (EQA-LAB-SOP40)

7.0. References
7.1. Baer DM, Good R and Orr J. A Quality Approach to Referral Lab Contracting.
Medical Laboratory Observer, July 1997. pp 62-67. This paper discusses how a
consortium of hospital laboratories rated and set up a contract with referral
laboratories, using a rating form similar to the one used in this chapter.
7.2. Nelson JC, Using Referral Labs Efficiently. Medical Laboratory Observer, June,
July, August1991. Dr. Nelson discusses the decision to send work to a reference
laboratory vs doing the work in Clients’ lab, how to evaluate and monitor the
quality of work done by the reference lab, and how to get the best service from a
reference laboratory.
7.3. National Committee for Clinical Laboratory Standards, Selecting and Evaluating a
Referral Laboratory. NCCLS Document GP9-A, Wayne Pa. www.nccls.org
This document was written as a guide to laboratories offering reference services as
well as those using them. It is intended as a standard for the laboratory industry,
setting expectations for good service.
7.4. Shaw, ST, "Selection of Reference Laboratory Services," Clinics in Laboratory
Medicine 1983;3:509-523.This article was written primarily for the clinical
laboratory community. It focuses on selection criteria for a reference laboratory and
the writing of an RFP (request for proposal).

8.0. Appendix
8.1. Technical evaluation scoring sheet (EQA-LAB-SOP01F1)

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EQA LOGO System Procedure SOP No: EQA-LAB-SOP02

Laboratory Department Version: 1

Section: General Quality Induction and Training Copy No:
Effective Date:
Awaiting HR procedure for training to adopt part of the policy and specify for lab

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EQA LOGO System Procedure SOP No: EQA-LAB-SOP03

Laboratory Department Version: 1

Section: General Quality Competency Assessment Copy No:
Effective Date:
Awaiting HR procedure for competency to adopt part of the policy and specify for lab.
Forms done

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EQA LOGO System Procedure SOP No: EQA-LAB-SOP04

Laboratory Department External Services and Internal Version: 1

Section: General Quality Supplies Copy No:
Effective Date:
1.0. Purpose/Applicability
1.1. Purpose
1.1.1. To provide direction for the processes and procedures to effectively work
with the procurement department to manage purchase and inventory
processes of equipment, supplies and reagents used in the path of
laboratory workflow
1.1.2. To describe the steps involved in ordering laboratory materials / reagents
from the HMIS.

1.2. Scope
1.2.1. This procedure applies to ordering of external services, equipment and
consumable supplies from procurement department
1.2.2. This procedure applies to all technologists and receptionists involved in
laboratory supply

1.3. Principle/Safety
1.3.1. Principle
N/A
1.3.2. Safety
1.3.2.1. Always wear appropriate personal protective equipment when
handling potentially infectious material and practice GCLP

2.0. Abbreviation, Definitions and Terms

2.1. Abbreviations
2.1.1. EQAL- Equity Afia Laboratories
2.1.2. SOP – Standard Operating Procedure
2.1.3. LAB – Laboratory
2.1.4. GLP- Good laboratory practice

2.2. Definitions and Terms

N/A

3.0. Sample type / Equipment and Materials/ Reagents/ Supplies

3.1. Sample type
N/A
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 3.2. Equipment
3.2.1. Computer

3.3. Materials/ Reagents/Supplies

3.3.1. Printing papers

4.0. Responsibility
4.1. This document applies to all staff that has been given responsibility to make order
requests in various sections of pathology department

5.0. Procedure
5.1. Process for selection and use of referral laboratory services
5.1.1. The laboratory has an established procedure for evaluating and selecting referral
laboratories
5.1.2. There are also established processes to ensure the referral laboratory’s
performance meets

5.2. Purchase of Equipment

5.2.1. The Laboratory in-charge and franchisee in consultation with the Chief
laboratory technologist develop performance specifications for each item/
category of equipment required in a section
5.2.2. The Chief laboratory technologist forwards the equipment request together
with specifications to the Equity Afia General Manager (GM) who
approves or rejects
5.2.3. If approved, the GM forwards the request to the Directors for
authorization of purchase
5.2.4. If approved, the procurement department requests for tenders from
suppliers of the equipment and proceed as per procurement policies to
order the equipment. The Chief lab technologist is involved in every step
of interviewing the suppliers of the equipment
5.2.5. The ordered equipment is then delivered and received in the laboratory.
The equipment is then handled as per SOP for equipment management

5.3. Advisory services

5.3.1. The laboratory has a part time Consultant pathologists who give advice on
choice of tests, interpret results among other technical issues
5.3.2. The pathologists are selected by the General Manager, Chief Clinical
Manager and by the MAC (Medical Advisory Committee)
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 5.3.3. The methods used are head hunting, recommendations among other
methods
5.3.4. The persons chosen are then vetted by the MAC during MAC monthly
meetings. If a consultant passes the vetting, then they are given a letter of
invitation/ service to work at Equity Afia health facilities

5.4. Supplier / Vendor selection

5.4.1. Laboratory is involved in selecting vendors of equipment, supplies and services
supplies via tendering committee
5.4.2. Chief Laboratory Technologist participates in meetings with identified
equipment, reagents and consumables and referral laboratory vendors (at least 3
different vendors) according to specifications
5.4.3. New items are evaluated before the vendors being approved
5.4.4. New items’ samples are accompanied with an evaluation form from
procurement to the laboratory for evaluation
5.4.5. After evaluation, the recommendations are written by the person
evaluating and the form is returned to EQA Head Office
5.4.6. Only accepted evaluations of consumables are considered when the
tendering committee is approving vendors

5.5. Purchasing Supplies and Reagents

5.5.1. If the item passes evaluation and tendering committee approves of the
vendor, the item is procured via HMIS procurement process
5.5.2. The laboratory orders items on HMIS and the chief laboratory technologist
evaluates and verifies the orders. The order is then forwarded to the
finance manager for approval and forwarding to the suppliers. The finance
manager completes purchase orders, processes them and forwards to the
suppliers. The requesting facility receives commodities directly from the
vendors. These are then stored in laboratory for use

5.6. Ordering items from suppliers

5.6.1. Open HMIS
5.6.2. Other steps to follow after HMIS is completed

5.7. Receiving items from Suppliers

5.7.1. The request is received by the Chief Laboratory technologist.
5.7.2. Other steps to follow after HMIS is completed

5.8. Rejecting items

5.8.1. Items are rejected due to the following:
5.8.1.1. If item is expired
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 5.8.1.2. If the item is leaking
5.8.1.3. If wrong item is brought instead of the one requested e.g.
control instead of calibrator.
5.8.1.4. Wrong volumes or quantities given.
5.8.1.5. Items with missing information e.g. lot number year of
manufacture.
5.8.1.6. New brand of item which have never been evaluated.
5.8.1.7. Rejected items are physically returned to surgical store and
simultaneously returned online.
5.8.1.8. The accepted items are stored either in the temperature
monitored refrigerator or room temperature as per the requirement.

5.9. Issuing items from Health facility store

5.10. Re-ordering

5.11. Handling of expired reagents / goods

5.11.1. Expired reagents and goods shall be disposed as per the procurement
policy for expired reagents, authorized use of expired and expired on-
board reagents and as per SOP for disposal of used/expired
chemicals/reagents and tissues

5.12. Inventory system

5.12.1. An inventory for equipment is maintained online at the laboratory
5.12.2. An inventory for reagents and consumables is maintained online and can
be printed on a monthly basis indicating the usage of the lab.

5.13. Quality Control/ Calibration

5.13.1. Laboratory in-charge or designee will do random Quality Control checks
to ensure that this SOP is implemented as written. If Quality control
checks reveal non-compliance to this SOP, the SOP deviations and
violations will be investigated, corrective and preventive action initiated,
implemented, reviewed and closed-out. All corrective and preventive
action should be documented in the corrective action form

5.14. Results
N/A

5.15. Reference values

N/A

5.16. Reporting
N/A

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 5.17. Limitations
N/A

5.18. Specimen Retention and Storage

N/A

6.0. Related Documents

6.1. Equipment management (EQA-LAB-SOP10)
6.2. Evaluation and selection of referral laboratories (EQA-LAB-SOP01)
6.3. Disposal of used/expired chemicals/reagents and tissues
6.4. Authorized use of expired and expired on-board reagents (EQA-LAB-SOP14)

7.0. References
N/A

8.0. Appendix
8.1. Document distribution list
8.2. Inspection of incoming goods form (EQA-LAB-SOP04F1)

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EQA LOGO System Procedure SOP No: EQA-LAB-SOP05

Laboratory Department Version: 1

Section: General Quality Good Documentation Practice Copy No:
Effective Date:
1.0. Purpose/Applicability
1.1. Purpose
To define the processes that must be followed when any handwritten entry is
required on a paper record or document. The purpose is to ensure that all paper
records with handwritten entries are legible and traceable with no doubt or confusion
over the interpretation of any entry. In addition the procedure aims to ensure that
paper records and documents are protected from any inappropriate amendments.

1.2. Scope
This document applies to ALL staffs in the Pathology Department who are involved
in the generation or recording of quality documents i.e. forms, registers, charts etc.

1.3. Principle/Safety
1.3.1. Principle
N/A

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviation, Definitions and Terms

2.1. Abbreviations
2.1.1. EQAL- Equity Afia Laboratory
2.1.2. ISO – International Organization for Standardization
2.1.3. GCLP – Good Clinical Laboratory Practice
2.1.4. SOP – Standard Operating Procedure
2.1.5. N/A-Not Applicable
2.1.5. QC-Quality Control
2.1.6. GDP – Good Documentation Practice

2.2. Definitions and Terms

2.2.1. Obliterating - to attempt to remove an entry, either by erasing or
covering it so that it cannot be seen, or by destroying the document.
2.2.2. Falsifying - to report something that is not true. E.g. signing that a task
has been performed when it has not, or entering a date and time that are
different from the actual date and time when the task was done.

3.0. Sample type / Equipment and Materials/ Reagent/ Supplies

N/A
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4.1. Responsibility
4.2. All pathology department staff i.e. technologists, phlebotomists, receptionists,
porters, nurse (s), secretary, housekeeping, assistant(s) must adhere to this SOP
4.3. All SQRs are responsible for ensuring all documentation generated within their
sections complies to this SOP and ensuring that any deviations have effective
Corrective and Preventive actions implemented within their sections

5.0. Procedure
5.1. This document provides basic guidelines for good documentation practices.
Correct, complete and legible documentation is an asset in every aspect of the
word. It is therefore critical that laboratory personnel are aware that proper
execution of documents is an important component of their everyday functions.
5.2. Unacceptable Documentation Practices:
5.2.1. Laboratory Quality records are often used to make critical decisions
regarding human life. As such they are legal documents. The following
documentation practices are considered unacceptable in the laboratory:
5.2.1.1. Destruction of Documents – Under no circumstances
should any document bearing original signature(s) be destroyed.
The correction techniques outlined below should be used whenever
there is a need to make corrections to an entire document.
Destruction of documents bearing original signatures may be
interpreted as attempting to hide important information.
5.2.1.2. Falsification of information.
5.2.1.3. Never use White-Out and Cover-Over-Tapes. The
correction techniques outlined in this document should be used
whenever corrections are to be made.
5.2.1.4. Obliteration - If the original entry cannot be seen,
it may be interpreted as hiding important historical
information.
5.2.1.5. Write-over - If you write a 1 and it is wrong; do not try
to change it into a 2. Correct it using proper correction
technique; as shown in this SOP.
5.2.1.6. Never use a pencil or attempt to erase information - all
documentation is to be completed in permanent BLACK or BLUE
ink. No pencils, water soluble or coloured inks can be used.
Exception to this is when reporting positive Tuberculosis (TB)
results in TB register, reporting positive screening results in blood
bank screening register where red pen is also acceptable.
Highlighters are also used by management when reviewing
External Quality Assurance (EQA) results
5.2.1.7. No spaces, lines or fields are to be left blank. If you’re not
going to use a space, put “N/A” in it and initial and date. If there

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 are several lines left blank: Put a diagonal line through them ,
add “N/A”, and your initials and date.

5.2.1.8. Never use symbols, e.g. ditto marks (“) or arrows ( ) to indicate
repetitive and consecutive information
5.2.1.9. Never sign for anyone else’s work. Only designated personnel
with management authorization can sign for another individual.
5.2.1.10. Never backdate - An example of backdating is when you forgot
to sign a document for a task you performed at an earlier date.
Enter the current date, and include a comment such as ‘signed on
14/12/07 for task performed on 10/12/07’.
5.2.1.11. Never take original Quality documents out of the Department
with the exception of patient reports. Only personnel
authorized by management may remove original documents from
the Department.

5.3. Correction Techniques:

5.3.1. Specific steps for correcting entry errors on quality documents must be
followed. When making a correction, the following steps should be
followed:
5.3.1.1. Draw a single line through the information to be corrected. The
information must remain legible - remember, never obliterate
information.
5.3.1.2. Write the correct information as close as possible to the error
being corrected
5.3.1.3. Then initial and date the correction. ALWAYS use the
current date
5.3.1.4. If there is a need to make adjustments to an entire document
e.g. if a form has been completed but with results on the
wrong patient, then the following steps should be followed:
5.3.1.4.1. Draw a single line across the entire document with
the wrong information.
5.3.1.4.2. Write the words OBSOLETE along the line.
5.3.1.4.3. Initial and date alongside the entry ensuring
that the already written information remains
as legible as possible.
5.3.1.4.4. Obtain a new form and write the words
‘CORRECTED/AMENDED COPY’ on the top of the
form.
5.3.1.4.5. Proceed with completing the form with the correct
information
5.3.1.4.6. Use comments (technique described in section
5.3.5 below) to enter the justification for need
for the corrections on the
‘CORRECTED/AMENDED COPY’
5.3.1.4.7. Initial and date the explanatory comment.
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 5.3.1.4.8. Staple the ‘OBSOLETE’ copy to the back of the
‘CORRECTED /AMENDED COPY’.
5.3.1.4.9. The ‘CORRECTED/AMENDED COPY’ and
the ‘OBSOLETE’ document shall be
maintained and filed together in the file for
Amended Reports.
5.3.1.4.10. For lab test reports sent to patient files or clinicians
only the CORRECTED/AMENDED report is
dispatched.
5.3.2. All signatures and dates must be the original handwritten signatures and
dates. The use of stamps, labels etc are not permitted. (Note: for review
and approvals a faxed copy of the document signature page is acceptable,
if the staff member is not present). Initialing of documents is also
acceptable.
5.3.3. To prevent inappropriate entries being added at a later stage no blank
spaces should be left. Cross through any spaces to be left blank and initial
and date the space. ‘N/A’ can be added if an entry is not applicable. See
below for examples of each:

5.3.4. If additional pages need to be attached to a document they should have all
pertinent information included (e.g. Record Title, document Number etc)
to associate them with the document and each page should be
signed/initialed and dated.
5.3.5. Where the reason for the correction is not obvious or there is insufficient
space to insert the correct entry place a circled number next to the
incorrect entry. Explain the correction or include the correct entry at the
bottom of the page (or suitable location on the page), including the circled
number to identify the text. Initial and date beside corrections and/or the
explanation notes. See below for examples: e.g.

5.3.6. Date Format:

5.3.6.1. Dates should be documented to avoid any confusion or the risk of
alteration. The date must be written and the format of day-month-
year must be used at all times. Examples of correct and incorrect
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 formats for the 2nd September 2006 are shown below.
Incorrect entries:
Correct entries:
 2006-09-02 or 2006-9-2
 02-Sep-2006
 09-02-2006 or 9-2-2006
 02-09-2006 or 02-09-06
 2/9/06 or2/9/2006
 02/09/2006 or 02/09/06
 02/09 or 2/9

5.3.7. Backdating and postdating are not permitted. The date entered must be the
date at which time the entry is made.
5.3.8. Making Comments: To justify adjustment to document. There are
times when you have to clarify information or justify actions taken. For
example:
5.3.8.1. Corrections- correction to a verification step or to the entire
document.
5.3.8.2. N/A- If a procedure has been discontinued or an area is not used.
5.3.8.3. Reference to other Documentation.
5.3.8.4. Use of additional or different equipment.
5.3.9. Documentation of Comments:
5.3.9.1. For good documentation of comments, it is important to
ensure that all comments are:
5.3.9.1.1. Initialed and dated.
5.3.9.1.2. Used only sparingly - Keep the information factual and
straight to the point.
5.3.9.1.3. Use a circled letter or number to link the comment to
the step for which it is intended.
5.4. Note:
5.4.1. Characteristics of GDP:
5.4.1.1. Accurate: Must contain accurate data and accurate account events.
5.4.1.2. Complete: Required information must be included in the
document.
5.4.1.3. Permanent: Information cannot be erasable nor be obscured in
anyway.
5.4.1.4. Legible: Documentation must be easy to read.
5.4.1.5. Timely: Activities must be documented at the time the work is
performed.
5.4.1.6. Clear: The documentation must be clear to limit misinterpretation
of what was performed and recorded.
5.4.1.7. Traceable: Documentation must provide information on:
5.4.1.7.1. Activity being documented
5.4.1.7.2. Individuals performing the activities
5.4.1.7.3. Materials and equipment used in the activity.
5.4.1.7.4. The activities preceding and following the process.
5.4.1.7.5. The location and proper identification of raw data.

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 5.5. Quality Control/Calibration
5.5.1. Quality Officer or designee will do random Quality Control checks to
ensure that this SOP is implemented as written. If Quality control checks
reveal non-compliance to this SOP, the SOP deviations and violations will
be investigated, corrective and preventive action initiated, implemented,
reviewed and closed-out. All corrective and preventive action should be
documented in the corrective action form.

5.20. Results
N/A

5.21. Reference values

N/A

5.22. Reporting
N/A

5.23. Limitations
N/A

5.24. Specimen Retention and Storage

N/A

6.0. Related Documents

N/A

7.0. References
7.1. Laboratory Quality Manual.
7.2. US FDA guidelines on Good Documenting Practices, Retrieved online from
www.fda.gov

8.0. Appendix
N/A

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 PRE-ANALYTIC PROCEDURES

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP07

Laboratory Department Version: 1

Section: Phlebotomy Sample Collection and Transportation Copy No:
Effective Date:
1.0. Purpose/Applicability
1.1. Purpose
To outline the steps involved in sample collection in the Laboratory to ensure;
 Proper collection and handling of primary samples
 Integrity of samples analyzed
 Reliability of the results generated for the physician

1.2. Scope
This procedure applies to all samples collected at the Equity Afia Health
Facilities’ Laboratories and all referring laboratories where possible

1.3. Principle/Safety
1.3.1. Principle
N/A

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviation, Definitions and Terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia Health care Facility
2.1.2. ISO – International Organization for Standardization
2.1.3. GCLP – Good Clinical Laboratory Practice
2.1.4. OP – Outpatient number
2.1.5. ANC – Antenatal Clinic
2.1.6. CSF – Cerebral spinal fluid
2.1.7. SAF – Abbreviation for EQA safety documents control numbers
2.1.8. SOP – Standard Operating Procedure
2.1.9. LAB – Laboratory

2.2. Definitions and Terms

2.2.1. Lab ref – Laboratory reference number; a unique sample identification
number given to a patient sample as per each request received

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3.0. Equipment and Materials/ Reagent/ Supplies
3.1. Equipment
3.1.1. Computer
3.1.2. Glucometer
3.1.3. Telephone
3.1.4. Smart card Machine
3.1.5. Bar code printer

3.2. Materials/Reagents/ Supplies

3.2.1. Needles
3.2.2. Lancets
3.2.3. Gloves
3.2.4. Vacutainer tubes
3.2.5. Tourniquets
3.2.6. Syringes
3.2.7. Swabs (dry & wet)
3.2.8. Adhesive Tape
3.2.9. Safety/ Sharps boxes

4.0. Responsibility
4.1. This document applies to all staff that has been given responsibility to collect
blood samples at EQA laboratories
4.2. The laboratory in-charge is responsible for the implementation of this procedure

5.0. Procedure
5.1. Receiving of requests
5.1.1. Requests are sent online by doctors and accessed by Technologists
/Phlebotomist at the laboratory
5.1.2. The patients are received at the laboratory’s phlebotomy room from the
doctor’s office where the Technologists /Phlebotomist identifies
him/herself to the patient and asks for his/her names
5.1.3. The Technologists/Phlebotomist checks the given names on the computer
and confirms the mode of payment i.e. cash, corporate or Smart card
patients
5.1.4. For walk-in patients and laboratory referrals, the patients are received at
reception, and sent to the laboratory for initiation of requests online by the
Technologists /Phlebotomist
5.1.5. If cash paying, queue the patient online and send them to the
cashier/receptionist to pay for the tests

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 5.1.6. If corporate or smart card patients, queue the patient and ask them to wait
in the reception area for their turn to be bled. If there is no queue attend to
the patients immediately
5.1.7. Ensure that tests have been paid for
5.1.8. Service the request and print barcode label (s) for the specified test(s)
5.1.9. For patients with urgent blood sugars, perform a rapid test using the
glucometer and directly post the report on the chemistry results module
online for the doctor to view
5.1.10. Obtain the sample from the patient as shown in section 5.3.
5.1.11. Place the printed barcode labels on the obtained samples’ container
5.1.12. Let the patient know the estimated wait time (turnaround time) before
results are released to the doctor
5.1.13. For fine needle aspirate requests, the patient is booked for as per the
Pathologist’s set schedule
5.1.14. For bone marrow aspirates see 5.2.2.6

5.2. Blood sample collection

5.2.1. General
5.2.1.1. Properly identify the patient using two unique identifiers.
Acceptable identifiers are patient first, middle and last name and
medical record number (-Patient number)
5.2.1.2. Verify diet restrictions. If patient has a fasting request or any
other restrictions, ensure that they have fasted for the required
hours or met any other requested requirements. If not instruct the
patient on how long to fast or any other diet restrictions for the
test and request them to come after adhering to that
5.2.1.3. Position patient lying on back with face up or sitting with the
appropriate site exposed
5.2.1.4. Wash hands thoroughly and apply clean gloves
5.2.1.5. Select venipuncture site except:
5.2.1.5.1. DO NOT USE an extremity with an A-V shunt
5.2.1.5.2. DO NOT USE a site with extensive scarring
5.2.1.5.3. DO NOT USE a site with a hematoma
5.2.1.5.4. DO NOT USE a site with an IV
5.2.1.6. Prepare overlying skin with alcohol using a circular motion
5.2.1.7. Before using, tap all tubes that contain additives to ensure that the
entire additive is dislodged from the stopper and the wall of the
tube
5.2.1.8. Make sure patient’s arm or other venipuncture site is in a
downward position to prevent reflux
5.2.1.9. Apply tourniquet to extremity 2 inches proximal to desired site
5.2.1.10. Identify target vein with palpation and visualization

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 5.2.1.11. Prepare/unwrap the unused needles/syringes in the presence of

the patient
5.2.1.12. Use thumb to apply tension downward distal to insertion site
5.2.1.13. Verbally state to patient that the venipuncture is starting and
insert the needle at a 15-30˚ angle and ¼ to ½ inches below the
intended entry into the vein

5.2.2. Venipuncture using evacuated tubes

5.2.2.1. If using evacuated tubes: Insert blood collection tube into holder
and onto needle up to the recessed guideline on the Vacutainers
adapter
5.2.2.2. Position the needle with the bevel up and the shaft parallel to the
path of the vein
5.2.2.3. Insert needle through skin at 15-30˚ angle and ¼ to ½ inches
below intended entry into vein
5.2.2.4. Grasp the flange of the needle adapter and push the collecting
tube forward until the needle punctures the stopper. Observe for
flow of blood into stopper. Maintain tube below the needle
5.2.2.5. Remove tourniquet as soon as possible once blood flow is
established
5.2.2.6. Keep constant, slight forward pressure on the end of the tube to
prevent release of shut-off valve and stop of blood flow
5.2.2.7. Fill the tube until the vacuum is exhausted and blood flow ceases
5.2.2.8. When blood flow ceases, remove the tube from the holder. The
shut-off valve recovers the point, stopping blood flow until the
next tube is inserted
5.2.2.9. Tubes containing additives should be mixed immediately upon
draw by inverting 5-10 times. To avoid hemolysis, do not mix
vigorously
5.2.2.10. To obtain additional specimens, insert the next tube into the
holder and repeat steps 5.3.19 - 5.3.21

5.2.3. Venipuncture using needle and syringe

5.2.3.1. Position the needle with the bevel up and the shaft parallel
to the path of the vein
5.2.3.2. Insert sterile needle or butterfly through the skin at a 15-30˚
angle ¼ to ½ inches below the intended entry into the vein
5.2.3.3. Pull back on plunger or syringe slowly until sufficient
volume of sample is achieved
5.2.3.4. Release tourniquet
5.2.3.5. Withdraw needle and syringe
5.2.3.6. Apply pressure to site with gauze pad

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 5.2.3.7. Pierce stopper of collection tube with needle; the evacuated tube
will fill to the correct amount of blood
5.2.3.8. Immediately activate the safety feature according to manufacturer
instructions and discard without assembly into a sharps container
5.2.4. Safely discard the used needle or/ and syringe into the sharps bin
5.2.5. Check patient’s arm to ensure bleeding has stopped
5.2.6. Apply gauze pad secured lightly with tape to the puncture site
5.2.7. Instruct patient to leave bandage in place for at least 15 minutes
5.2.8. Place specimen on rack for delivery into the laboratory

5.3. Venipuncture procedure when multiple specimens are collected:

5.3.1. Obtain blood specimen using the following “order of draw”:
5.3.1.1. Blood culture tubes or vials
5.3.1.2. Coagulation tube/citrate (BLUE TOP)
5.3.1.3. Non-additive / plain tube (RED TOP)
5.3.1.4. Serum tube with or without clot activator, with or without gel
(RED or GOLD TOP)
5.3.1.5. Heparin tube with or without gel plasma separator ( GREEN)
5.3.1.6. EDTA tube (LAVENDER, PINK or PEARL TOP)
5.3.1.7. Glycolytic inhibitor ( GRAY TOP)

5.4. The following general procedures should be observed when collecting the
following samples:

Blue Top tubes The volume requirements of blue top tubes for coagulation tests such as
PT or PTT are very specific. The tube should be filled precisely to the
required volume with a free flowing sample
Ethanol (Alcohol) Betadine or other non-alcoholic solution should be used for disinfecting
testing the arm prior to sampling. Do NOT use alcohol swabs

5.5. Blood Culture collection procedure

5.5.1. For each request for blood cultures on adults when a time or location is not
specified by the doctor, two sets of two bottles will be drawn. Each set of
aerobic and anaerobic blood culture bottles will be obtained from two
different sites. Samples will NOT be taken from an arterial line, heparin
lock or a subclavian IV unless specifically ordered by the attending
physician
5.5.2. After selecting a good phlebotomy site, the tourniquet will be released and
the site disinfected
5.5.3. The site will be cleansed first with an alcohol swab using a spiral motion
moving from the site outward
5.5.4. Prepare the site using an iodine swab using the same motion working from
the site outward. Allow the iodine to dry before drawing specimen

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 NOTE: Any deviation from routine collection should be noted on the request
form or sample bottles
5.5.5. Perform the venipuncture and draw the sample according to procedure.
Sample should flow freely
5.5.6. Carefully change syringe needle and blood transfer device and place 8-
10mL of blood into each vial using aseptic technique. Be sure not to
contaminate bottle tops before entering bottle with needle. Label and send
to lab as soon as possible. Treat patient according to current post-
phlebotomy procedures. (See venipuncture methods lists on previous
pages.)

5.6. Capillary puncture

5.6.1. Capillary puncture may be used for obtaining specimens in infants or in
adults where venipuncture is difficult. Specimens from infants under the
age of 6 months are usually collected by heel prick. Above 6 months,
finger prick collection is usually used. Microtainers are available for
collection and are color-coded similar to vacuum tubes – red for serum
specimens, lavender for EDTA whole blood or plasma and green for
heparin whole blood or plasma
5.6.2. The capillary puncture should be made with a sterile lancet according to
current nursing or laboratory capillary collection procedure
5.6.3. The first drop of blood containing tissue and tissue fluid should be wiped
away, and the blood collected from the clean flow of blood from the
wound
5.6.4. Care should be taken not to squeeze the finger or leg excessively in order
to avoid sample hemolysis
5.6.5. After collection, the collection tube should be capped and inverted several
times to mix the anticoagulant. Do NOT shake. Label each tube before
sending. (See labeling requirements 5.7.)
5.7. Labeling
5.7.1. Label all blood tubes at patient’s time of draw. Bar code labels are printed
and used to label the sample containers
5.7.2. Ensure sample tubes are labeled with the patient name, patient number,
date, department and your initials as the technologist/phlebotomist
5.7.3. Place labeled specimens in biohazard bag for urine, stool and sputum
samples.
5.7.4. Discard gloves and wash hands

5.8. Caution
5.8.1. The phlebotomist is responsible for the pre-analytical factors that may
influence sample testing e.g.
5.8.1.1. Hemolysed samples – this can be avoided by:
 mixing samples gently
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  avoiding exposure to extreme temperatures (hot or cold)
 not expelling blood via the needle
5.8.1.2. Improper labeling
5.8.1.3. Collecting a sample into an inappropriate tube/container
5.8.1.4. Using leaking containers
5.8.1.5. Collecting inadequate sample

5.9. Sample registration

5.9.1. All samples shall be adequately serviced and given the appropriate unique
laboratory reference number by the phlebotomist or receptionist
5.9.2. All samples shall be registered in the laboratory Master register before
being delivered into the laboratory sections for analysis
5.9.3. Samples that do not conform to the above requirements shall be rejected
according to the sample acceptance, accessioning and rejection SOP
(EQA-LAB-SOP08)

5.10. Urgent/ Verbal Requests

5.10.1. Urgent test requests for are highlighted in red online by the doctors and/or
nurses when they post a request online
5.10.2. Hard copy requests received at the laboratory are marked as urgent by the
doctor or the phlebotomist is called and alerted to the emergency
5.10.3. The phlebotomist collects the sample giving these particular patients
priority (while alerting the other patients to avoid complaints)
5.10.4. The phlebotomist then either places a red sticker with the word
“URGENT’ on the request form at the top and on the sample.
Alternatively, a red marker is used to mark the form and sample with the
word “URGENT”.
DO NOT obscure any patient information on the request or sample.
5.10.5. The sample and request are then serviced, registered and delivered
immediately into the laboratory
5.10.6. The technologist at the bench is also alerted by the phlebotomist or
receptionist to the urgency of the situation
5.10.7. Urgent samples are given first priority
5.10.8. Verbal requests either on phone or otherwise should only be accepted in
emergency cases where writing down is not possible
5.10.9. The verbal request shall be recorded in the verbal requests register (by the
person receiving the request) and include the patient’s names, hospital
number, location of patient, tests requested, doctor requesting and the date
and time of request and initials of the person receiving the request. This

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 information should be read back to the requestor as heard and written for
clarification
5.10.10. The phlebotomist or technologist who receives this request shall follow
up and ensure a soft or hard copy request is made by the requestor

5.11. Sample Transportation

5.11.1. All diagnostic specimens shall be transported to and from the laboratory
in a manner as to prevent contamination of workers, patients or the
environment
5.11.2. Sample should as much as possible be transported immediately after they
have been obtained from the patient so as to safeguard the quality of the
results that shall be obtained from the processing of these samples
5.11.3. Samples being transported within EQA should be placed in plastic
biohazard specimen bags and placed in cool boxes that are leak proof
5.11.4. Specimens with needles are NOT accepted
5.11.5. Samples transported by couriers should be triple-packaged. The original
specimen container must be leak-tight and inserted into a secondary bag
with sufficient absorbing material to absorb accidental spill of the entire
specimen volume. The outer packaging (cool box) must be designated and
labeled “for biohazards only” and secured against movement during
transport. An icepack should be placed in the cool box to maintain the
appropriate transportation temperatures
5.11.6. The operator of motor vehicles that transport specimens must be trained as
to the hazards they transport and documentation availed to the laboratory
5.11.7. See Laboratory users’ handbook which gives other specifications for
sample transportation
5.11.8. All laboratory staff and other persons who transport samples to and from
the laboratory shall also be trained on proper handling of biohazard
material
5.11.9. Samples transported by EQA drivers/couriers shall be delivered using
delivery books to enable the laboratory to track the samples

6.0. Related Documents

6.1. Laboratory Users’ Handbook
6.2. Sample Acceptance, Accessioning and Rejection SOP (EQA-LAB-SOP08)

7.0. References
7.1. ISO 15189:2007
7.2. Shands at UF Sample collection Manual
7.3. Gribbles Pathology Collection Manual

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8.0. Appendix
N/A

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP08

Laboratory Department Sample Acceptance, Accession and Version: 1

Section: Phlebotomy Rejection Criteria Copy No:
Effective Date:
1.0. Purpose/Applicability
1.1. Purpose
To outline the steps involved in the reception or rejection of samples in the
Laboratory to ensure the integrity of the specimen received and the reliability of the
results generated for the requesting client.

1.2. Scope

This procedure applies to all samples received at the Equity Afia Health Facility
(EQA) Laboratories

1.3. Principle/Safety
1.3.1. Principle

N/A

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP (EQA-SAF-P004)

2.0. Abbreviation, Definitions and Terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia health facility
2.1.2. ISO – International Organization for Standardization
2.1.3. GCLP – Good Clinical Laboratory Practice
2.1.4. MRN – Medical records number
2.1.5. HMIS-Health Management Information System

2.2. Definitions and Terms

2.2.1. Lab ref – Laboratory reference number; a unique sample identification
number given to a patient sample as per each request received

3.0. Sample type, Equipment and Materials/ Reagent/ Supplies

3.1. Sample type
N/A

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 3.2. Equipment
3.2.1. Computer

3.3. Materials/Reagents/ Supplies

N/A

4.0. Responsibility
4.1. The Laboratory in-charge is responsible for the implementation of this procedure
4.2. All Technologists/Phlebotomist are responsible for the implementation of this
procedure

5.0. Procedure
5.1. Receiving Samples
5.1.1. Observe biosafety guidelines for handling of Blood-borne pathogen
specimens
5.1.2. Ensure all request forms accompanying samples into the laboratory have
been properly initiated, serviced and given a unique laboratory reference
number in the HMIS
5.1.3. Ensure the requests contain the following minimum information:

Patient’s name, age, gender, attending physician, tests requested, date and
time sample was collected (for referred samples) and pertinent clinical
information. See also laboratory users’ handbook section
5.1.4. Cross check information on the request form and the specimen container. If
the information is not the same and also does not comply with 5.1.3 above,
go to 5.2
5.1.5. Where the information is the same, register the request form in the
Laboratory master register [Online or hardcopy] and distribute the samples
and request forms into the laboratory as per tests requested
5.1.6. Where the sample is outsourced, follow the procedure for Referral of
samples (EQA-LAB-SOP40)

5.2. Rejecting a Sample/ Request

Specimens may be rejected in the following situations:

5.2.1. Mismatched specimens and /or request forms
5.2.2. Unlabeled specimens: The doctor, nurse, or referring facility shall be
notified and requested to identify the specimen or send another sample. The
sample is sent back with the porter for the requesting person to identify it

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 5.2.3. Incomplete labels: All the samples must have the patient’s full details. The
collector should be contacted to correct any problems. Samples for
newborns should be indicated as “Baby of” (B/o) to avoid mix-up with
mother’s sample. Also, cord blood should be indicated as so on both
request form and sample.
5.2.4. Requests accompanied by lipemic, icteric, or haemolysed specimens will
have the condition noted on the laboratory result. In addition, when the
result is submitted by telephone, the condition of the submitted specimen
(i.e. lipemic, icteric or haemolysed) will be conveyed to the individual
receiving the results. Telephone reporting shall follow protocol set down in
SOP for Reporting and release of results (EQA-LAB-SOP38)
5.2.5. Contaminated specimen or request forms: The requesting person will be
called and requested to submit a new specimen/form (see 5.4 for
exceptions)
5.2.6. Improper sample container for requested assay: Technologists will not
perform a test if the specimen is not in the acceptable container. See
individual SOPs for sample types and Laboratory users’ handbook for
proper sample containers
5.2.7. Insufficient quantity of specimen submitted for the testing requested:
Contact doctor/physician, clinic, or send phlebotomist and have the
patient’s blood re-drawn or have the physician prioritize test requested for
analysis (however this should be highly discouraged and only done in
critical or patients from whom a redraw is not possible)
5.2.7.1. Full blood count 4mls or (1ml microtainer)
5.2.7.2. CD4 Test 4mls
5.2.7.3. Liver function test 4mls
5.2.7.4. Urea/electrolytes/creatinine 4mls
5.2.7.5. All other chemistry tests 4mls
5.2.7.6. Coagulation tests 4mls
5.2.7.7. Viral load 4mls X 2
tubes

Note: If there are exceptions to this requirement (e.g. emaciated patient or very
small child) for which a sample would have to be shared between tests, this is to
be clearly communicated. Not less than 2mls whole blood is to be collected.
5.2.8. Use of expired collection devices
5.2.9. Mislabeled specimen
5.2.10. Leaking or broken specimen container
5.2.11. Specimen subjected to extensive delay or extreme temperatures
5.2.12. Empty containers
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 5.3. Corrective actions
5.3.1. Take appropriate action to correct the problem for all improperly collected
or handled samples. If necessary have the sample recollected as soon as
possible
5.3.2. Document all actions taken on the specimen rejection register for all
rejections and in addition the specimen rejection forms for external
rejections i.e. referral laboratory samples. Indicate the patient’s name,
patient number, Department/, reason for rejection, the person contacted,
date and time of notification, action taken, and name of the person making
the notification/rejection
5.3.3. Notify the physician/doctor if a delay in performing the analysis will
occur; this allows him/her to make appropriate decisions
5.3.4. Any amendments/corrective action made by the requesting department
shall also be noted in the rejection register
5.3.5. The laboratory in-charge shall review all rejected request forms/ specimens
weekly and a report given in the Monthly staff meeting. The report is also
communicated to the Franchisee.

5.4. Courtesy and exceptions

5.4.1. In all the above situations, notify the concerned persons of the problem
exhibiting a professional courteous attitude.
5.4.2. Whenever possible, cooperate with the physician to determine alternate
testing in the case of “hard to draw patients”, especially infants and burn
patients
5.4.3. Samples such as cerebrospinal fluids, bone marrow and
Histological/cytological samples and samples from discharged patients
shall not be discarded but the clinics or referral hospitals should be
requested to correctly label or correct the detected mistake so samples can
be processed. Any amendments made especially labeling, or correction of
mismatched samples and request, shall be signed for by the nurse or doctor
and recorded as so by the Technologist/phlebotomist in the rejection book.

6.0. Related Documents

6.1. Laboratory Users’ Handbook
6.2. Reporting and release of results SOP (EQA-LAB-SOP38)
6.3. Laboratory Master register (EQA-LAB-RG01)
6.4. Sample Rejection Register (EQA-LAB-RG02)

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 7.0. References
7.1. ISO 15189:2007
7.2. Ministry of Health (GOK) guidelines for sample rejection

8.0. Appendix
8.1. Sample rejection form (EQA-LAB-SOP08F1)

EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP10

Laboratory Department Version: 1

Section: Phlebotomy Emergency Phlebotomy Procedure Copy No:
Effective Date:
1.0. Purpose/Applicability
1.1. Purpose
This SOP will describe the steps to be taken in the case of an emergency phlebotomy
procedure.

1.2. Scope
Technologists, phlebotomists, nurses, clinicians and other personnel who perform
phlebotomy at the EQA laboratory

1.3. Principle/Safety
1.3.1. Principle
N/A

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviation, Definitions and Terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia Health Facility
2.1.2. N/A- Not applicable
2.1.3. SOP – Standard Operating Procedure
2.1.4. LAB – Laboratory
2.1.5. CPR- Cardio pulmonary resuscitation
2.1.6. IAW- In accordance with
2.1.7. GCLP- Good clinical laboratory practice
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 2.1.8. BP- Blood pressure
2.1.9. SAF- Safety
2.1.10. RG- Register

2.2. Definitions and Terms

2.2.1. Lab ref – Laboratory reference number; a unique sample identification
number given to a patient sample as per each request received

3.0. Equipment and Materials/ Reagent/ Supplies

3.1. Equipment
3.1.1. Telephone
3.1.2. Emergency bell
3.1.3. BP machine

3.2. Materials/Reagents/ Supplies

3.2.1. Gloves
3.2.2. Tourniquets
3.2.3. Cold compressors
3.2.4. Vomitus basin
3.2.5. Paper towel/tissue paper
3.2.6. Spirit
3.2.7. Sharps container
3.2.8. Adhesive tape
3.2.9. Needles
3.2.10. Swabs(dry & wet)
3.2.11. Warm washcloths

4.0. Responsibility
4.1. All EQA laboratory staff and other staff responsible for sample collection are
expected to follow the laid down procedure and implement it

5.0. Procedure
5.1. The patient feels fainting/convulsing sensation:
5.1.1. In the event a patient starts feeling unconscious or appears to be passing
out. follow these steps:
5.1.1.1. Release the tourniquet and withdraw the needle from the
vein at the first sign of reaction during the phlebotomy procedure.

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 5.1.1.2. Immediately discard all the sharps into the sharps box to
avoid accidental needle stick
5.1.1.3. Apply pressure to the site by placing a dry swab using
adhesive tape and shout for help
5.1.1.4. If possible, provide physical support to the patient by
laying him/her on back and lower the patients head and arms to
promote blood flow to the brain.
5.1.1.5. Loosen the patients clothing, take the vital signs (bp, pulse)
ensuring patient has an adequate airway, is breathing and has a
pulse, continue monitoring the vital signs if need be administer
oxygen.
5.1.1.6. Patient who has fainted should fully recover under
supervision before being dismissed from your care at least for
20minutes. They should also be instructed not to drive for at least
30minutes
5.1.1.7. If the patient does not respond call the doctor/nurses on
duty by shouting or ringing emergency bell at phlebotomy room
5.1.1.8. The phlebotomists SHOULD document the incidence on
the incident register
5.1.1.9. Notify the laboratory in-charge, Nurse in-charge or doctor
on duty immediately
5.2 A patient feels nauseated/vomiting
5.2.1 In the event a patient starts feeling nauseated during phlebotomy follow
these steps:
5.2.1.1 Release the tourniquet and withdraw the needle from the vein at the
first sign of reaction during the phlebotomy procedure.
5.2.1.2 Immediately discard all the sharps into the sharps box to avoid
accidental needle stick.
5.2.1.3 Apply pressure to the site by placing a dry swab using adhesive tape.
5.2.1.4 Give the patient a vomitus basin and paper towel/ tissue paper
5.2.1.5. Give the patient water to rinse out his or her mouth.
5.2.1.6. Call for assistance to get the patient on a couch until the symptoms
subside
5.2.1.7. NEVER leave nauseous patient unattended. Patient SHOULD fully
recover before being dismissed from your care.
5.2.1.8. The phlebotomists SHOULD document the incidence on the
Phlebotomy incident register
5.2.1.9. Notify the laboratory in-charge, nurse in-charge or doctor on duty
immediately
5.3 Cardiac arrest or pulmonary arrest
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 5.3.1 Shout for help immediately and notify doctor/nurses (emergency team) by
pressing the emergency bell if available
5.3.2 Check 5.1
5.3.3 If the patient is in cardiac arrest begin CPR immediately and continue
until the emergency team comes. CPR is breathing and chest
compressions given to those who are thought to be in cardiac arrest
5.4 Care of hematomas
5.4.1 A hematoma is a bruise that causes `` BLACK and BLUE’’ discoloration
of the skin. It is a small collection of blood under the skin. Initially it may
appear as a small lump. This may occur following a phlebotomy
procedure. There might be slight pain or discomfort at the sight of the
hematoma. The skin will reabsorb this blood within several days. During
the reabsorption process the skin will appear `` BLACK AND BLUE’’.
Any extension of the area of discoloration represents the body’s
mechanism of removing the blood. This extension of discoloration DOES
NOT mean that it is continuing to bleed. As the blood is reabsorbed, skin
colors of brown and yellow will be seen.
5.4.2. First and most importantly, do not engage in activity that requires
strenuous use of the arm. For the first 24 hours after blood collection,
place crushed ice in a plastic bag, wrap it in cloth and hold on the
hematoma for approximately 15minutes. Repeat at intervals during the
first 12hours. If you secure the cold pack to the site of the hematoma with
a pressure dressing, make sure the dressing is not applied too tightly. If the
pressure becomes too tight as evidenced by tingling or cold fingers,
discoloration of the hand or lower arm, discomfort, unwrap the strapping
and rewrap it with less pressure. Don’t keep the strapping for more than 15
minutes at any one time. Do not go to bed with the strapping.
5.4.3. After 24 hours apply warm compressors at intervals. A warm washcloth
may be used for this purpose. The warm washcloth should be applied on
the hematoma for 15minutes. Warm compressors will quicken the
reabsorption process of blood and relieve any tenderness that may be
present.
5.4.4. Hematomas are prevented from occurring by applying DIRECT
PRESSURE to the site of the blood collected area. Direct pressure will
prevent blood from seeping out of the vein, allow for the needle hole in
the vein to close, and therefore decrease the chance of a hematoma
developing. Maintain direct pressure to the site for 3 to 5 minutes after
blood collection
5.5 Quality control

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 5.5.1. Laboratory in-charge or designee will do random Quality Control checks
to ensure that this SOP is implemented as written. If Quality
Control checks reveal non –compliance to this SOP, the SOP deviations
and violations will be investigated, corrective and preventive action
initiated, implemented, reviewed and closed –out. All corrective and
preventive action should be documented in the corrective action form.
5.5.2. Patients SHOULD not be pricked more than 2 times, if unable to draw
blood ask for assistance from other technologist, nurse or the requesting
doctor.
5.5.3. ALWAYS check the needle gauge before the insertion, tubes SHOULD be
checked periodically e.g. for expiry dates, if broken etc.

5.6. Results
N/A

5.7. Reference values

N/A

5.8. Reporting
N/A

5.9. Limitations
N/A

5.10. Specimen retention and storage

N/A

6.0. Related Documents

6.1. Laboratory users’ handbook

7.0. References
7.1. Shands at UF Sample collection Manual
7.2. Gribbles Pathology Collection Manual
7.3. NCCLS Clinical Laboratory Technical Procedure Manuals, GP2-A2, 3rd Edition;
Approved Guideline, 1996
7.4. Strasinger & Lorenzo, Phlebotomy Workbook, F.A. Davis Company, 1996, pp 183-
184
7.5. Becton Dickinson Vacutainer Systems insert, Franklin Lake, NJ, 1996
7.6. Henry, John Bernard MD, Clinical Diagnosis and Management by Laboratory
Methods, 1991, pp 7-9
7.7. NCCLS Publication, H3-A7, Technique for Venous Puncture, 1987
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8.0. Appendix
N/A

ANALYTIC PROCEDURES

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP11

Laboratory Department Version: 1

Section: General Quality Equipment Management Copy No:
Effective Date:
1.1. Purpose/Applicability
1.2. Purpose
This procedure outlines the minimum requirements for general laboratory equipment
management. It outlines the controls that will be in place for:
1.1.1. Ensuring that minimum qualification requirements for equipment are
achieved and documented at installation and for routine use.
1.1.2. Identification of laboratory equipment
1.1.3. Equipment records
1.1.4. Equipment maintenance and servicing
1.1.5. Labeling for equipment calibrations, for defective equipment, and for out
of service equipment
1.1.6. Equipment Safety Inspections
1.1.7. Requalification of equipment that has been out of-service or has been out
of the direct control of the laboratory
1.1.8. Laboratory equipment decontamination, transport/movement and storage
1.1.9. De-commissioning of Equipment

1.3. Scope
This procedure applies to all Laboratory Instruments and Analytical systems that
are housed and/or used in all Equity Afia laboratories. All staff within EQA using
the laboratory equipment defined is required to follow this procedure.

1.4. Principle/Safety
1.4.1. Principle
N/A

1.4.2. Safety
1.4.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP
1.4.2.2. All Contractors and Service Engineers will be required to
understand and Follow universal safety precautions before
commencing any work in EQA laboratories
1.4.2.3. Equipment will be decontaminated before service by external
Contractors and Service Engineers. Decontamination is also
applicable to equipment being taken out of the lab i.e. For Repairs
or Disposal

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2.0. Abbreviation, Definitions and Terms
2.1. Abbreviations
2.1.1. EQA – Equity Afia Health care Facility
2.1.2. ISO – International Organization for Standardization
2.1.3. GCLP – Good Clinical Laboratory Practice
2.1.4. N/A - Not Applicable
2.1.5. CAPA - Corrective and Preventive Action
2.1.6. PPM - Planned Preventive Maintenance

2.2. Definitions and Terms

2.2.1. Laboratory Equipment – Refers to all instruments and analytical systems
required and used in the provision of laboratory services.
2.2.2. Instrument- A measurement tool which can be used to obtain the value of
a quantity
2.2.3. Laboratory Analytical System – A combination of instruments organized
to function as a single unit capable of performing multiple process steps
and various examinations with little or no human intervention.
2.2.4. Installation Qualification (IQ) – Testing and documentation process that
confirms the equipment was installed successfully, and according to the
manufacturer's specifications for correct and reliable functioning. IQ
confirms: that the correct equipment primary and ancillary components are
installed, that the expected equipment parameters are set, that all utilities
are sized appropriately per manufacturer’s specifications and that the
equipment does not negatively impact other laboratory equipment or the
surrounding environment. The IQ will also provide the basic description
and purposes of the equipment.
2.2.5. Operation Qualification (OQ) - Testing and documentation process that
proves that the equipment complies with the operational process
requirements, and works as intended throughout its operational range. OQ
confirms: that the equipment operates as required for its application when
working in its operational environment, that required SOPs are ready, and
that users have been trained.
2.2.6. Performance Qualification (PQ) - Testing and documentation process that
proves the equipment performs specific processes consistently and as
intended during normal operational use according to approved SOPs, and
remains in compliance with regulatory and user's expectations.
2.2.7. Requalification – Refers to repeats of the performance qualification (PQ)
to confirm that the equipment is still performing consistently and in
compliance with regulatory and user expectations, and that the equipment
is able to meet the specifications achieved in the initial PQ.
Requalification is required when the equipment has been taken out of
service or sent off site for maintenance.
2.2.8. Preventive Maintenance (PM) also Planned Preventive Maintenance
(PPM) – Regular scheduled maintenance performed on equipment to

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 extend the useful life of the equipment and diagnose potential for
equipment malfunction before corrective maintenance is required
2.2.9. Calibration – Process of verification against certified standards, which is
performed on equipment periodically to check for accuracy of quantitative
measurements. Adjustments are made as necessary and out of
specification results are evaluated for impact to process/results

3.0. Sample type, Equipment and Materials/ Reagent/ Supplies

3.1. Sample type
N/A

3.2. Equipment
N/A

3.3. Materials/Reagents/ Supplies

N/A

4.0. Responsibility
4.1. It is the responsibility of the Laboratory in-charge to:
4.1.1. Where relevant, prepare specifications and validation reports for new and
modified equipment
4.1.2. Write an individual SOP for all equipment which defines all the
maintenance requirements (e.g. Routine, Preventive, Calibration etc.)
regardless of whether carried out by an external agent
4.1.3. The requirements may be defined in the service contract referenced in the
SOP
4.1.4. Prepare the planned maintenance schedules for all equipment items
4.1.5. Have maintenance charts for all routine maintenance on equipment that
require documentation of maintenance

5.0. Procedure
5.1. Identification of Laboratory Equipment:
5.1.1. Equipment belonging to EQA will be assigned an Equity Afia ‘Asset
Number’ by Biomedical engineering Department in consultation with
other Departments
5.1.2. The Equipment Owner/User shall contact the Chief laboratory
technologist or Designee and the following minimum information on the
equipment should be documented before being housed in the laboratories:
5.1.2.1.1. Instrument Description.
5.1.2.1.2. Instrument Make and Model
5.1.2.1.3. Instrument Serial Number
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 5.1.2.1.4. Section in which instrument is to be housed
5.1.2.1.5. Scheduled Installation Date
5.1.3. The Laboratory in-charge together with Chief laboratory technologist shall
update the Laboratory asset register
5.1.4. The Laboratory in-charge or Designee shall prepare the space for the new
equipment and a training plan for the equipment users

5.2. Equipment Records:

5.2.1. The Laboratory in-charge or Designee shall open a file for the equipment
and proceed to initiate the Laboratory Equipment Qualification Log,
Appendix 2.
5.2.2. The Laboratory in-charge or Designee will be responsible for coordinating
its completion (Installation, Operation and Performance Qualification
processes), including coordinating development of operational SOPs (or
incorporating into existing SOPs), as well as establishing the calibration
and preventive maintenance procedures per requirements for the
equipment. Manufacturer recommendations for safe handling, transport,
storage and use of the equipment shall be followed and shall be
incorporated into the applicable SOPs
5.3. Laboratory Equipment Master File (Book of Life): The Equipment master file
will be maintained by the Laboratory in-charge or Designee and will have the
following minimum information within:
5.3.1.1. Laboratory Equipment Qualification Log
5.3.1.2. Fit for purpose statement log
5.3.1.3. Maintenance service agreements/contracts
5.3.1.4. Maintenance schedules
5.3.1.5. Safety inspection reports
5.3.1.6. Movement inventory form
5.4. The Laboratory in-charge or Designee will be responsible for reviewing the
Laboratory Equipment Qualification Log sand Laboratory Equipment Master File
for completeness, and for verifying that adequate procedures for calibration and
preventive maintenance are in place prior to releasing the equipment as approved
for use. The Laboratory in-charge or Designee will be responsible for
maintaining the Laboratory Equipment Master File
5.5. All significant events experienced in the life of the equipment including but not
limited to damages, malfunction, repair and final decommissioning of the equipment
shall be documented on the Equipment Corrective Maintenance and Repair Form
Appendix 3. The equipment users, maintenance personnel, repair-men, etc., will all
be responsible for completion of this Form. The Equipment Corrective Maintenance
and Repair Form shall be maintained in the vicinity of the equipment (in the
laboratory), such that it is readily available for the life span of the equipment, and
will be archived when the equipment is decommissioned.
5.5.1. NOTE: All Equipment Corrective Maintenance and Repair Forms for a
laboratory may be kept in a central binder within that department, as long
as there are separate sections for each of the individual pieces of

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 equipment within that department or filed in separate folders each for a
particular equipment

5.6. Equipment Fit For Purpose Statement log:

5.6.1. This form, Appendix 4, will be filled for all equipment and filed in the
master files within the EQA laboratory

5.7. Labeling of Equipment:

5.7.1. Calibration Required: Calibration Stickers shall be affixed (such that it is
easily referenced) on all equipment in the Laboratory that require periodic
calibration. A Calibration required Sticker, Appendix 5 shall be used to
fulfill this requirement
5.7.1.1. Calibration Not Required: Major Equipment that does not
require calibration shall be affixed with a sticker bearing the
wording: ‘No Calibration required’, Appendix 5. Minor or
Small equipment which do not require calibration will not be
labeled with this sticker.
5.7.1.2. Calibration Required Before Use: For equipment that
requires calibration only at the time of use, e.g. a pH meter, a
sticker with the wording ‘Calibration Required Before Use’,
Appendix 5, shall be affixed to the equipment.
5.7.2. Equipment Out of Service: For equipment that has been taken out of
service due to malfunction, replacement, or other, a sign or sticker with
the wording ‘Do Not Use! Equipment Out-Of Service’, Appendix 5,
shall be affixed to the equipment. The Out-of-Service status should be
recorded in the Equipment Corrective Maintenance and Repair Forms and
management approval obtained to authorize the decision

5.8. Equipment Maintenance and Servicing:

5.8.1. Certified equipment servicing contracts will be used where appropriate
and as determined by Equity Afia Management. Documentation pertaining
to service contracts shall be filed within the Equipment Master File
5.8.2. All equipment servicing shall be coordinated through the laboratory in-
charge or Designee. Whenever any servicing is performed, the in-charge
must secure documentation detailing the service performed, parts replaced,
and adjustments made to equipment. The Equipment Servicing Sheet,
Appendix 6 (or equivalent from a certified service contractor) shall be
used to document the servicing performed. When service sheet is provided
by the manufacturer or contractor, there will be no need to fill the
Equipment Servicing Sheet

5.9. Equipment Safety Inspections:

5.9.1. All equipment will be tested and inspected for safety annually. Safety test
and inspection of equipment performed in-house (By the Laboratory in-
charge or Designee) or by certified independent contractors. This should
be documented on a form appropriate for the equipment. Inspections can
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 also be done when doing the Equity Afia Internal Audits and applicable
documentation filed by the laboratory in-charge in the Equipment Master
File. Any issues arising from the safety inspection shall be documented on
the Laboratory Non-Conformance Corrective Action and Clearance
Report (Audit NCR Form)
5.9.2. Upon acceptable completion of the annual equipment safety test and
inspection and documentation filed, staff will be informed of equipment
which is not safe to use and sticker reading “EQUIPMENT NOT SAFE
FOR USE” placed on the equipment. This sticker will help to deter away
staff who may want to use the equipment due to lack of information. The
sticker will be placed on the equipment such that staff can spot and read
the label. The sticker must contain the following information: appliance
number, date, and signature of person executing the test or inspection.

5.10. Requalification of Equipment:

5.10.1. Requalification may be necessary for equipment that has been out-of
service for repair or servicing, or that has been out of the direct control of
the laboratory. For such equipment, the following minimum requirements
shall apply:
5.10.1.1. For Equipment that has been out-of-service for a period of less
than 1 year, a Performance Qualification (PQ) as well and
calibration and preventive maintenance should be performed and
approved to re-qualify the equipment. The PQ shall be conducted
and documented to repeat the equipment’s original PQ, and the
new status of the equipment documented on the Equipment
Corrective Maintenance and Repair Forms, Appendix 3. The re-
qualified equipment shall maintain the same Asset Number and
Equipment File
5.10.1.2. For equipment that has been out-of-service for a period greater
than or equal to 1 year, a complete Installation Qualification
(IQ), Operational Qualification (OQ) and Performance
Qualification (PQ) as recommended by the equipment
manufacturer during initial commissioning of the equipment
shall be performed. The IQ, OQ and PQ as well as re-
qualification shall be documented on a new Laboratory
Equipment Qualification Log, appendix 2, and the new status
of the equipment documented on the Equipment Corrective
Maintenance and Repair Forms, Appendix 3. The re-
commissioned equipment shall maintain the same Appliance
number and Equipment File.

5.11. Equipment Decontamination, Transport/Movement and storage:

5.11.1. Equipment Decontamination:
5.11.1.1. All laboratory equipment must be free of hazardous materials
(i.e., biological, chemical, radiological) prior to
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 transportation/movement from one destination to the other in
order to protect both the movers and those receiving the
equipment
5.11.1.2. Once the equipment user has deemed the equipment “safe for
transport/Service/Disposal”, they must fill out the Owner
Declaration of Equipment contamination status form,
Appendix 7. This form is affixed to the equipment and the
laboratory in-charge notified for signature to verify that
decontamination has been completed
5.11.1.3. Not all items from the laboratory will require a hazard
assessment, such as computers, chairs, bookshelves, etc.
However, if the movers are concerned for any reason about an
item, which does not require this signed document, they may
request one prior to transport

5.11.2. Equipment Transport/Movement:

5.11.2.1. Care must be taken when transporting Equipment either inter-
laboratory, intra-laboratory, or to/from the workshop, to avoid
damage and loss. An Equipment movement Inventory Form,
Appendix 8 will be filled in duplicate. One copy is to
accompany the equipment and the other copy to be in the
Equipment Master File. The form will have the following
information:
5.11.2.1.1. Equipment description and Asset Number
5.11.2.1.2. Destination of the equipment
5.11.2.1.3. Reason for the movement
5.11.2.1.4. General condition of the equipment before packing
5.11.2.1.5. Person packing/sending the equipment
5.11.2.1.6. Courier name/ID
5.11.2.1.7. Date Equipment returned to -EQA
5.11.2.1.8. Person receiving the equipment
5.11.2.1.9. General Condition of the equipment upon return
5.11.2.2. Note:
5.11.2.2.1. Some equipment have their factory made packaging
box, which must be stored well for future use. If the
equipment does not have specified box, then the person
packing the equipment should look for a strong box and
use soft material like Styrofoam or paper shreds to
support the equipment.
5.11.2.2.2. Signage e.g. ‘FRAGILE’, ‘THIS SIDE UP,’ ‘DO
NOT PLACE ANY THING ON TOP,’ ‘DO NOT
TILT’ must be put on the packaging box to warn the
courier and anybody who might handle the equipment
5.12. Quality Control/Calibration
5.12.1. The Laboratory in-charge and Chief Laboratory technologist will do
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 random checks to ensure that this SOP is implemented as written. If
Quality Control yields unexpected results, root cause analysis will be done
and corrective and preventive action initiated, implemented, reviewed and
closed. All corrective and preventive action should be documented in the
corrective action form.

5.13. Results
N/A
5.14. Reference values
N/A
5.15. Reporting
N/A
5.16. Limitations
N/A
5.17. Specimen Retention and Storage
N/A

6. Related Documents
6.1. Training Procedure ( )
6.2. Method verifcation procedure (EQA-LAB-SOP13)

7. References
7.1. NCCLS, A Quality System Model for Health Care; Approved Guidelines; HIS-A
Vol. 22
7.2. Technical Manual of American Association of Blood Banks 13th Edition, 1999,
Page 5
7.3. Quality Manual, International Federation of Red Cross and Red Crescent Societies,
1998, Pages 23-24
7.4. The Gazette of India extra ordinary notification G.S.R. 245 (E) dated 5th April 1999,
new Delhi, Part II Sec. 3 (i), Page 40

8. Appendix
8.1 Laboratory equipment qualification log (EQA-LAB-SOP11F1)
8.2 Equipment corrective maintenance and repair form (EQA-LAB-SOP11F2)
8.3 Equipment fit for purpose statement (EQA-LAB-SOP11F3)
8.4 Calibration required sticker, No calibration required’ sticker, Calibration required
before use’ sticker, Do not use! Equipment out of service’ sticker (EQA-LAB-
SOP11F4)
8.5 Equipment service sheet (EQA-LAB-SOP11F5)
8.6 Owner declaration of Equipment contamination status (EQA-LAB-SOP11F6)
8.7 Equipment movement inventory: (EQA-LAB-SOP11F7)
8.8 Equipment Maintenance performance form (EQA-LAB-SOP11F8)
8.9 Equipment Maintenance and calibration schedule form (EQA-LAB-SOP11F9)

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP12

Laboratory Department Version: 1

Section: General Quality Equipment Maintenance Copy No:
Effective Date:
1.0. Purpose/Applicability
1.1. Purpose
To outline instructions to be followed when maintaining equipment at The Equity
Afia Health Facilities’ (EQA) Laboratories

Equipment Maintenance is one of the visible aspects of good equipment/ asset

management.  It is a service that aims to ensure equipment function.  When
maintenance is not done, or it is delayed for too long, the risk to continued
operation rises rapidly because of the increasing likelihood of parts failure. 
Maintenance is a proactive way to guarantee equipment does what it is supposed
to do every time you want to use it. 

1.2. Scope
This document applies to all the instruments and equipment used within EQA
laboratories. All staffs within EQA laboratories are required to follow this
procedure

1.3. Principle/Safety
1.3.1. Principle
N/A

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when
handling potentially infectious material and practice GCLP
1.3.2.2. All Contractors and Service Engineers will be
required to understand and Follow universal safety
precautions before commencing any work in EQA
laboratories
1.3.2.3. Equipment will be decontaminated before service
by external contractors and Service Engineers.
Decontamination is also applicable to equipment being
taken out of the lab i.e. For Repairs or Disposal

2.0. Abbreviation, Definitions and Terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia Health care Facility

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 2.1.2. ISO – International Organization for Standardization
2.1.3. GCLP – Good Clinical Laboratory Practice
2.1.4. SOP – Standard Operating Procedure
2.1.5. CAPA – Corrective Action, Preventive Action
2.1.6. IAW – In accordance with

2.2. Definitions and Terms

2.2.1. Preventive maintenance actions are those actions intended to prevent or
discover functional failures. Preventive maintenance includes actions taken to
prevent equipment from failing, such as changing the oil, cleaning filters,
calibrating, etc.
2.2.2. Alterative maintenance is the performance of authorized changes or
modifications to upgrade or change the design of installed equipment
2.2.3. Corrective maintenance, are actions taken to fix equipment that has failed or
is not working to desired performance standards

3.0. Sample type / Equipment and Materials/ Reagent/ Supplies

N/A

4.0. Responsibility
4.1. It is the responsibility of laboratory in-charge to:
4.1.1. Where relevant, prepare specifications and verification reports for new and
modified equipment
4.1.2. Write an individual SOP for all equipment which defines all the
maintenance requirements (e.g. Routine, Preventative, Calibration etc.)
regardless of whether carried out by an external agent. The requirements
may be defined in the service contract referenced in the SOP.
4.1.3. Prepare the maintenance schedules for all equipment items. The schedule
is to include:
4.1.3.1. Preventive
4.1.3.2. Routine
4.1.3.3. Extra maintenance
4.1.3.4. Cleaning and sanitation
4.1.3.5. Corrective maintenance
5.1. Procedure
5.2. Maintenance overview:
5.2.1. Identify each item of equipment in the unit that requires maintenance
5.2.2. Ensure all items have a Serial Number and Asset Number
5.2.3. Staff should be trained on the relevant procedures for routine maintenance
and preventive maintenance including cleaning or decontamination of
equipment
5.2.4. For all maintenance procedures the laboratory in-charge or Designee will
write operator instructions for maintenance or avail manufacturer’s Users’
Manual to the staff
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 5.2.5. Names and contact information of service personnel will be prepared by
the laboratory in-charge or Designee. Maintain a documented log of
servicing for all items
5.2.6. Frequency of calibration shall be determined by the laboratory in-charge
or Designee and shall be referenced to the manufacturer’s users’ manual.
Cleaning and decontamination of equipment shall be done before the
equipment is serviced, removed from the laboratory or disposed.
5.2.7. Prepare a complete equipment and instrumentation list consisting of the
following headings:
5.2.7.1. Equipment name / description
5.2.7.2. Asset Number or Serial Number
5.2.7.3. Model Identification
5.2.7.4. Calibration Schedule
5.2.8. Calibration documentation shall include:
5.2.8.1. Frequency
5.2.8.2. Referenced documents or what was done and when
5.2.8.3. Performed by
5.2.9. Performance Check:
5.2.9.1. Frequency
5.2.9.2. Referenced documents or what was done and when
5.2.9.3. Performed by
5.2.10. Preventive maintenance:
5.2.10.1. Frequency
5.2.10.2. Referenced documents or what was done and when
5.2.10.3. Performed by
5.2.11. Routine maintenance:
5.2.11.1. Frequency
5.2.11.2. Referenced documents or what was done and when.
5.2.11.3. Performed by
5.2.12. Cleaning and decontamination:
5.2.12.1. Frequency
5.2.12.2. Referenced documents or what was done and when
5.2.12.3. Performed by

5.3. The laboratory in-charge or Designee will maintain a list of all equipment and
instruments used in the and copies kept in HMIS to ensure all equipment within
the department are documented
5.4. The Section quality representative or designee will classify equipment in their
sections according to two classes i.e.:
5.4.1. Equipment which needs the routine maintenance to be documented
5.4.2. Equipment which do not need the documentation of routine maintenance
5.5. Equipment which does not need the documentation of routine maintenance shall
have their external parts cleaned to prevent dust from accumulating

5.6. Maintenance Schedules:

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 5.6.1. Draw up suitable schedules by maintenance type and frequency or by
equipment type. Define forward dates for the completion of maintenance
and record the date of actual performance in the schedule
5.6.2. The laboratory in charge will prepare, maintain the schedule and ensure it
is in the HMIS

5.7. Service contracts:

5.7.1. Contracts need to be in place for all equipment items maintained by an
external agent
5.7.2. Each service contract shall define exactly what is carried out / the
frequency and by whom it is completed
5.7.3. At the completion of the service, a maintenance report is to be supplied,
signed by the contractor, the Technologist present for verification of
completion and the laboratory in-charge or Designee. The report shall
detail the work carried out by the contractor

5.8. Repair & breakdown:

5.8.1. Operating instructions for each item of equipment shall identify the steps
required to be taken in the event of a fault or breakdown, and shall identify
who is responsible for organizing service or replacement. The operating
instructions and the steps required to be taken in the event of a fault or
breakdown can be obtained in the Manufacturer’s user manual. The person
organizing service or replacement of the equipment is the laboratory in-
charge or designee
5.8.2. Records for all errors and corrective actions are to be maintained for all
equipment items. In the event of equipment breakdown, it is essential that
it be clearly labeled and identified as being out of service. The label “Do
Not Use! Equipment Out-Of service” is affixed on the equipment where
it is visible to all staff

5.9. Maintenance overdue:

5.9.1. The laboratory in-charge or Designee shall determine the suitability for
ongoing use of any equipment that has passed its due date for routine
maintenance (where this routine maintenance does not involve
calibration). The in-charge must document their reasons for continuing to
use an item of equipment that is overdue for maintenance. Where
appropriate this should include explanation (and supportive evidence
where available) that product quality has not been compromised by this
delay in maintenance. Where possible, documentary evidence from the
manufacturer supporting this decision should be provided. Steps should be
taken at the next instance of routine maintenance to evaluate whether any
discernible damage has been caused to the equipment by the delay in
maintenance

5.10. Documentation

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 5.10.1. Document the details of all routine and corrective maintenance in the
equipment Corrective Maintenance Form
5.10.2. Maintain records of service reports of all equipment. Corrective
Maintenance or Repairs will be documented in the Equipment Corrective
Maintenance and Repair Form (EQA-LAB-SOP11F2)
5.10.3. Maintain a file of all manufacturer's instructions or manuals and where
possible close to the equipment
5.10.4. Record the name, address and telephone number of the service engineer to
be contacted in case of need
5.10.5. For each equipment item so identified, calibration and maintenance
requirements (i.e.calibration/maintenance interval,
calibration/maintenance SOP, equipment identifier, and source of
calibration or maintenance, if performed externally) shall be developed
and documented. Additional requirements shall include the following:
5.10.5.1. All equipment with expired calibration or maintenance
overdue dates shall be affixed with a “Do Not Use!
Equipment Out-Of service” label pending calibration,
maintenance, or withdrawal from inventory
5.10.5.2. The required calibration and/or maintenance intervals shall
be established based upon the manufacturer’s
recommendations, the level of projected use, the usage
environment, and usage history
5.10.5.3. Specific calibration and maintenance instructions shall be
provided based upon the equipment manufacturer’s
recommendations. Calibration standards to be used should be
identified. If no calibration standard exists, then the basis or
justification of the calibration method must be documented, any
limitations on use shall be specifically defined
5.10.5.4. The completed equipment Calibration and Maintenance
Reports shall be forwarded to the respective Section Head or
his/her designee for review and approval. All comments shall be
resolved to the reviewer’s satisfaction.
5.10.5.5. The equipment Calibration and Maintenance Reports shall
be used by the Section Head to track ongoing equipment
calibration and maintenance status.
5.10.5.6. Failure to complete scheduled calibration or maintenance
within the interval defined in the Section’s Equipment Calibration
and Maintenance Requirements shall be considered a non-
conformance, subject to the corrective and preventive action
process defined by EQA Corrective and Preventive Action
Policy
5.11. Note:
5.11.1. Report equipment problem and complaint to the Laboratory in charge or
designee for assistance if you are unable to resolve the problem on time.
5.11.2. Maintenance is cheap; it is repairs that are expensive. Equipment fails
by wearing out, rattling loose, being attacked by chemicals, being used
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 wrongly by employees, lubricant leaks from it and contaminants like dirt,
water and product find their way into your equipment’s internals.
5.11.3. If the operating equipment fails you can lose an absolute fortune in lost
production and knock-on costs. You will inconvenience your customers
and they will want to go to another supplier. You will get aggressive with
your superiors, peers and employees and destroy workplace friendships.
You can even send your operation broke with hasty, poor decisions.
You can even lose your job because of seemingly poor performance. All
this can come to pass if you let your plant and equipment fail. That is how
important equipment maintenance is to you. If you want to stop
equipment failures and protect yourself and your work then do the
maintenance the equipment needs before it fails.

5.12. Quality Control/Calibration

5.12.1. The Laboratory in-charge and Chief Laboratory technologist will do
random Quality Control checks to ensure that this SOP is implemented as
written. If Quality control checks reveal non-compliance to this SOP, the
SOP deviations and violations will be investigated, corrective and
preventive action initiated, implemented, reviewed and closed-out. All
corrective and preventive action should be documented in the corrective
action form.

5.13. Results
N/A

5.14. Reference values

N/A

5.15. Reporting
N/A

5.16. Limitations
N/A

5.17. Specimen Retention and Storage

N/A
6.0. Related Documents
N/A

7.1. References
7.2. Technical Manual of American Association of Blood Banks 13th
Edition, 1999, Page5.
7.3. Quality Manual, International Federation of Red Cross and Red
Crescent Societies,
1998, Pages 23-24.

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 7.4. The Gazette of India extra ordinary notification G.S.R. 245 (E) dated
5th April 1999,
new Delhi, Part II Sec. 3 (i), Page 40.

EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP13

Laboratory Department Version: 1

Section: General Quality Method Evaluation and Verification Copy No:
Effective Date:
1.0. Purpose/Application
1.1. Purpose
This SOP outlines experiments that help to prove that an analytical method is
acceptable or fit for its intended purpose at The Equity Afia Health Facilities’ (EQA)
Laboratories

1.2. Scope
This document applies to all technologists/ medical lab scientists within EQA
Laboratories

1.3. Principle & Safety

1.3.1. Principle
The accuracy, precision, and reportable range of a new test or method
must be evaluated before putting it into use to verify the specifications
established by the manufacturer. The new method must also be correlated
to the method currently in use so that differences in reference range will be
communicated to physicians when the new method is put into use

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when handling
potentially infectious material (biological specimens) and practice
GCLP (EQA-SAF-P004)

2.0. Abbreviations, Definitions and Terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia Health care Facility
2.1.2. SOP- Standard operating procedure
2.1.3. SD – Standard Deviation
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 2.1.4. CV – Coefficient of Variation
2.1.5. CAPA – Corrective action and Preventive action
2.1.6. NCCLS – National council for clinical laboratory services
2.1.7. TEa – Total Error Allowable
2.1.8. CRM – Certified Reference Materials
2.1.9. GCLP- Good clinical laboratory practice

2.2. Definitions and Terms

2.2.1. Correlation – The degree to which two or more variables are related and
change together i.e. comparing the results given by two different
equipment on the same sample and calculating the variation
2.2.2. Validation – Process of confirming that a product, service or test method
has met the requirement for which it was intended

3.0. Equipment and Materials/ Reagents/ Supplies

3.1. Samples
3.1.1. Pooled samples are recommended

3.2. Equipment
3.2.1. Instrument (s) to be validated
3.2.2. Printer
3.2.3. Computer

3.3. Materials/ Reagents/Supplies

3.3.1. Samples
3.3.2. Quality Control material
3.3.3. External Quality Assurance results
3.3.4. Reference material
3.3.5. Analytical Pipettes
3.3.6. De-ionized water
3.3.7. Ruler
3.3.8. Calculator
3.3.9. Test tubes
3.3.10. Reagents and consumables shall depend on method being validated

4.0. Responsibility
4.1. It is the responsibility of the Laboratory in-charge or Designee to ensure that all
technical staff are trained on the implementation of this SOP

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 4.2. It is the responsibility of all EQA Laboratory staff to ensure that all new methods are
evaluated and verified before use. All methods to be adopted in EQA Laboratories
must pass these experiments before use. They should also ensure that re-
verification is done when required

5.0. Procedure
5.1. General Requirements
5.1.1. This SOP will cover the procedures used to verify a new method within
EQA. The following experiments will be described: Accuracy, precision
and linearity (where possible) studies. Analytical range, detection limit,
quantization limit, and robustness will be done only when in-house
methods are developed or manufacturer’s original methods are modified.
Manufacturer’s claims will be used

5.1.2. Quantitative methods are used to measure the concentration of an

analyte; usually expressed as a continuous range of values. The scope of
verification of quantitative tests at EQA Laboratories will consider:
5.1.2.1. Accuracy
5.1.2.2. Precision
5.1.2.3. Linearity where possible

5.1.3. Qualitative methods are used to determine the presence or absence of an

analyte; dichotomous results (positive/negative, normal/abnormal) Method
Verification will include:
5.1.3.1. Sensitivity
5.1.3.2. Specificity
5.1.3.3. Predictive Value where possible

5.2. When to verify:

5.2.1. Verify your method when:
5.2.1.1. A method should be evaluated when it is necessary to
verify that its performance parameters are adequate for use for a
particular analytical problem. For example:
5.2.1.1.1. New method developed for particular problem;
5.2.1.1.2. Established method revised to incorporate
improvements or extended to a new analytical testing;
5.2.1.1.3. When quality control indicates an established method is
changing with time;
5.2.1.1.4. When established method is used in a different
laboratory, or different instrumentation;
5.2.1.1.5. To demonstrate the equivalence between two methods,
e.g. a new method and a standard

5.3. QUANTITATIVE METHOD VALIDATION EXPERIMENTS:

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 5.3.1. Precision Experiment
5.3.1.1. The precision of an analytical method is the amount of scatter in the
results obtained from multiple analysis of the same sample
5.3.1.2. Objective: To estimate imprecision or random error
5.3.1.3. Sample choice: The sample matrix should be identical to that of the
sample to be analyzed with the new method and it should represent the
concentrations of laboratory working range (e.g. Quality control
material and patient sample)
5.3.1.4. Experiment period: The experiment shall be done for a minimum of 3
days
5.3.1.5. Required Runs: Minimum of 10 runs per analyte per level per day
5.3.1.6. Procedure: Run a minimum of 10 runs per concentration level per
analyte per day. Duplicate run is recommended but not a must.
The minimum of two concentration levels is used in the experiment to
cover normal and abnormal ranges.
Note: Samples are usually analyzed twenty times per concentration
and results recorded. However, a minimum of 10 runs per
concentration level will be allowed when resources do not allow
analysis of 20 samples per concentration level as is the case at
EQA Laboratories
5.3.1.7. Calculation: Calculate your mean, SD and CV.
5.3.1.8. Result Interpretations: Use method performance specifications
or criteria approved by the management to interpret your results. Where no
method performance specifications or criteria are available proceed to use
manufacturer’s claims to accept or reject your results. Laboratory
imprecision should always be less than manufacturer imprecision claims.

5.3.2. Accuracy (Trueness) Experiment

5.3.2.1. The accuracy of a method is the closeness of the measured value to the
true value for the sample. Practical assessment of trueness relies on
comparison of mean results from a method with known values, that is,
trueness is assessed against a reference value (i.e. True value or
conventional true value). Two basic techniques are available:
5.3.2.1.1. Checking against reference values from a characterized
material i.e. External Quality Assurance
5.3.2.1.2. Checking against reference values from another
characterized or verified method
5.3.2.1.3. Retrospective External Quality Assurance values or
mean
5.3.2.2. Objective: Performed to estimate systematic error
(Inaccuracy/Bias).
5.3.2.3. Sample choice: The sample matrix should be identical to that of
the sample to be analyzed with the new method and it should
represent the concentrations of laboratory working range i.e.:
5.3.2.3.1. Certified Reference Materials (CRM) or EQA material
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 5.3.2.3.2. In-house standards
5.3.2.3.3. Simply typical samples
Note: There are advantages to using CRMs, since these have
known stability and homogeneity, and additionally give an
indication of bias with respect to international standards. On the
other hand, CRMs are costly and may not be representative of
typical samples.

5.3.2.4. Experiment Period and required runs: Minimum ten between

days runs per analyte
5.3.2.5. Procedure: Accuracy is usually determined in two ways:
5.3.2.5.1. Use of samples with known concentration of the
analyte. National Institute of Standards and Technology
(NIST) reference standards or equivalent are often used.
Such well- characterized samples are usually not
available in countries like Kenya.
5.3.2.5.2. In absence of reference standards, EQA Laboratories
will use External Quality Assurance material or any
other reference material.
Retrospective EQA results can be used or
actual internal quality control material can
be analyzed
5.3.3. Method Comparison experiment
5.3.3.1. Compare test results from the new method with results from an
existing alternate method that is known to be accurate (reference
method).
5.3.3.2. Calculations/Statistics: Plot the new method values in Y axis of
the graph versus the reference values in X axis. The relationship
of the two methods will be shown by the closeness of the values
to the line of identity and the intercept with Y-axis. Use linear
regression to estimate the slope and intercept
5.3.3.3. Result Interpretations: Correlation coefficient(r) value above
0.95 is ideal. Any other method performance metrics approved by
the management e.g. Six sigma will be used by EQA Laboratories
to accept or reject a method.

5.3.4.Linearity Experiment
5.3.4.1.A linearity study verifies that the sample solutions are in a
concentration range where analyte response is linearly
proportional to concentration. EQA Laboratories will adopt
manufacturers’ linear ranges. However when samples are
available, EQA Laboratories will do linearity experiment as per
this SOP.
5.3.4.2.EQA Laboratories will use manufacturer linear ranges provided in
the method manual. The Laboratory in-charge or Designee will
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 verify that the manufacturer linear ranges cover the reference
ranges used in EQA. If linearity experiment is required, follow the
procedure outlined in this SOP
5.3.4.3.Objective: Linearity range provides confidence that the new
method will provide accurate results within a range that covers
laboratory reportable range
5.3.4.4.Sample Choice: Two pools of samples one with an analyte value
close to zero or detection limit or zero and the other one
with a higher concentration or close to the expected upper
limit of the laboratory working ranges. The lowest and
highest measurable
limits provided in the manufacturer’s method manual or insert
will be used
5.3.4.5.Experiment Period: Performed as a single experiment
5.3.4.6.Procedure:
5.3.4.6.1. Prepare dilutions using two pools - one near the zero
level or close to the detection limit or zero and the other
near or slightly above the expected upper limit of the
working range. Alternatively use lowest and highest
measurable limits provided in the manufacturer’s
method manual or insert. Determine the total volume
needed for analysis, select appropriate volumetric
pipettes and then proceed as outlined below:
5.3.4.6.1.1. Label the low pool "Pool 1" and the high
pool "Pool 5"
5.3.4.6.1.2. Prepare Mixture 2 (75/25) as a mixture of 3
parts Pool 1 plus 1 part Pool 5
5.3.4.6.1.3. Prepare Mixture 3 (50/50) as a mixture of 2
parts Pool 1 plus 2 parts Pool 5
5.3.4.6.1.4. Prepare Mixture 4 (25/75) as a mixture of 1
part Pool 1 plus 3 parts Pool 5
5.3.4.6.1.5. Run one portion of the samples in validated
equipment and the other portion in the
equipment you are evaluating
5.3.4.7. Calculation/Statistics: Plot the mean of the measured
values on the y-axis versus the known/assigned values from
validated equipment on the x-axis. Visually inspect the plot for a
linear relationship. Manually draw a straight line through as many
of the points as possible and estimate the reportable range
5.3.4.8. Result Interpretation: Linearity range should cover all the
values that are within the linear portion of the plot
Note: From the Linearity experiment you will also get the
following method verification elements:
5.3.4.8.1. Limit of Detection (LoD).
5.3.4.8.1.1. Independent sample blanks measured once
each, Express the LoD as 3SD above the sample
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 blank (this assumes that a signal more than 3SD
above the sample blank could only have arisen
from the blank much less than 1% of the time,
and therefore is likely to have arisen from
something else, such as the measurand). Getting
a true sample blank can be difficult.
5.3.4.8.2. Limit of Quantitation (LoQ)
5.3.4.8.2.1. This is the lowest concentration of analyte
that can be determined with an acceptable level
of accuracy and precision. This is calculated by
analyzing 10 independent sample blanks (as
above). The LoQ corresponds to the sample
blank value plus either;
 5SD
 6 SD or
 10 SD
This may involve stripping serum to obtain a
sample blank (getting a true sample blank can
be difficult). Another method is to fortify
aliquots of a sample blank at various analyte
concentrations close to the LoD. Calculate the
SD of the analyte value at each concentration.
Plot SD against concentration and put a value to
the LoQ by inspection

5.3.5.Working and Linear Ranges

5.3.5.1. For any quantitative method, it is necessary to determine the range of
analyte concentrations over which the method may be applied. The LoD
or LoQ will determine the lower end. At the upper end of the concentration
range limitations will be imposed by various effects depending on the
instrument response system. Within the working range there may exist a
linear response range. Note that regression calculations on their own are
insufficient to establish linearity. To do this a visual inspection of the line
is required. Random distribution about the straight line confirms linearity.
Systematic trend indicate non-linearity.

5.3.6.Validation of Quantitative Methodologies approved by competent

authorities:
5.3.6.1. Before the laboratory decides on the method and degree of
verification required, the company from which the product is
purchased should be contacted and all method validation
information requested

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 5.3.6.2. The laboratory can then use this information to decide on
the extent of method verification required. The minimum
requirements for method verification are:
5.3.6.2.1. The analyst makes himself or herself completely
familiar with a new method
5.3.6.2.2. Information on manufacturers’ method performance
claims.

5.4.QUALITATIVE METHOD VALIDATION EXPERIMENTS:

5.4.1. Sensitivity and Specificity
DISEASE
Present Absent
Positive True Positive (TP) False Positive (FP)
TEST
Negative False Negative (FN) True Negative (TN)

Sensitivity = TP/TP+FN
Specificity = TN/TN+FP

5.4.2. Verification of Qualitative Methods approved by Competent

authorities:
5.4.2.1. Qualitative analysis can be treated in a slightly different
way. Qualitative analysis is effectively a yes/no measurement at a
given threshold of analyte concentration. EQA Laboratories will
use any of the following two methods for verification:
5.4.2.1.1. Analyze 10 known positive and 10 known negative
samples i.e. EQA samples or CRM or IQC. After
analysis calculate the sensitivity and specificity by
comparing results from a validated/Verified method or
a reference laboratory with the results obtained from the
new method. After analysis calculate the sensitivity and
specificity
5.4.2.1.2. Once the method is established Trueness must be
established by using the same methodologies. However,
statistical analysis is not required, as trueness cannot be
expressed qualitatively by standard deviation. The
analyst must therefore assess the results of the
method/reference comparisons objectively and make a
decision on the strength of the results. Again for
qualitative methods, precision cannot be expressed as a

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 standard deviation, but may be expressed as true and
false positive (and negative) rates

5.4.3. Validation of methods not approved by competent bodies and “in-

house” methods reproduced from published methods
5.4.3.1. As mentioned, all tests which are not approved by
competent bodies or are “in-house” methodologies will undergo
full validation before they are used in EQA Laboratories.
Depending on the analyte and the methodology, EQA management
team has to decide which method performance parameters need to
be characterized in order to validate the method. EQA management
will select the parameters to be validated depending on the
availability of the required resources
5.4.3.2. The majority of published methods is well established and
only requires EQA Laboratories proving the level of performance,
claimed by the published method is achievable within the
department. However if any modification of the methodology is
made, or a totally new method enhancement is being introduced
into EQA, then a full extensive method development/validation
will be required
5.5. Note:
5.5.1. Semi-quantitative tests will be validated using the same methodologies
and reported either quantitatively or qualitatively
5.5.2. Where available, EQA Laboratories may choose to use manufacturer’s
instructions on how to perform method validation experiments

5.6. Availability of Current Test Methods to Clients

5.6.1. Upon request by a client, the Laboratory in-charge or designee shall avail
a copy (uncontrolled) of the current method for any specified laboratory
procedure. The client will be provided any information available for the
method, including performance specifications, either in writing, verbally,
or will be shown the procedure manual and data depending upon the
preference of the requestor.

5.7. Changes in Methodology Notification to Clients

5.7.1. If there is a change in the methodology for a particular procedure which
results in a significantly different interpretation, a MEMO will be sent to
all physicians and copied to the franchisee, or an explanatory footnote will
be added to the test report

5.8. Quality Control

5.8.1. The Laboratory in-charge and Chief Laboratory technologist will do
random Quality Control checks to ensure that this SOP is implemented as
written. If Quality control checks reveal non-compliance to this SOP, the
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 SOP deviations and violations will be investigated, corrective and
preventive action initiated, implemented, reviewed and closed-out. All
corrective and preventive action should be documented in the corrective
action form.

5.9. Results
5.9.1. The verification procedure and results must be documented and a report
written and filed within the department
5.10. Reference values
N/A
5.11. Reporting
N/A
5.12. Limitations
N/A
5.13. Specimen Retention and Storage
N/A

6.0. Related Documents

6.1. Equipment Management procedure (EQA-LAB-SOP11)

7.0.References
7.1.R. Albert and W. Horwitz, Analytical Chemistry, 1997, 69, pp 789-790
7.2.CIPAC Handbooks, CIPAC Publications, Black Bear Press, Cambridge, UK.
7.3.W.J. Dixon, Ann. Math. Stat.1951, 22, p 68
7.4.J.M. Green, A practical guide to analytical method validation, Analytical Chemistry,
1996, May 1, pp 305A/309A
7.5.F.E. Grubs and G. Beck, Technometrics, 1972, 14, p 847
7.6.EC document SANCO/3030/99 rev.4 11/07/00 Technical Material and Preparations;
Guidance for generating and reporting methods of analysis in support of pre- and
Post registration data requirements for Annex II (part A, Section 4) and Annex III
(Part A, Section 5) of Directive 91/414
7.7.U.S. Pharmacopoeia 25, pp 2256-2259
7.8.VICH (International Cooperation on Harmonization of Technical Requirements for

Registration of Veterinary Medicinal products: GL 1 – Validation of Analytical

Procedures: Definition and Terminology
7.9.Vessman et al, IUPAC, Pure Appl. Chem., 2001, 73(8), pp 1381–1386
7.10.The Fitness for Purpose of Analytical Methods. A Laboratory Guide to Method
Validation and Related Topics. P. De Bievre et al, EURACHEM Guidance
document

8.0.Appendix:
8.1. Quantitative Equipment Method verification form (EQA-LAB-SOP13F1)
8.2. Qualitative Equipment Method Verification form (EQA-LAB-SOP13F2)
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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP14

Laboratory Department Lot to Lot Validation and Parallel Version: 1

Section: General Quality Testing Copy No:
Effective Date:
1.0. Purpose/Application
1.1. Purpose
The purpose of this procedure is to provide a procedural template for use at Equity
Afia Heath Facilities’ (EQA) Laboratories when developing a program for parallel
testing. The procedure is intended to be used by staff as a guide while
developing parallel testing procedures

1.2. Scope
This document applies to all the EQA staff given the responsibility to perform lot to
lot validation and parallel testing using this standard operating procedure

1.3. Principle & Safety

1.3.1. Principle
To reassure the performance of each new kit before use, each new lot of
reagent must be tested and confirmed with samples with known results i.e.
EQA samples, Patient samples or Quality Control samples before or
concurrent with routine use. Document results of parallel testing on
reagent log sheets

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP (EQA-SAF-
P004)
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2.0. Abbreviations, Definitions and Terms
2.1. Abbreviations
2.1.1. EQA – Equity Afia Health care Facility
2.1.2. SOP- Standard operating procedure
2.1.3. GCLP – Good Clinical Laboratory Practice
2.1.4. EIA – Enzymatic Immunoassay
2.1.5. ELISA-Enzyme Linked Immuno-sorbent Assay

2.2. Definitions and Terms

2.2.1. Competent Authority - Person or organization that has the legally
delegated or invested authority, capacity, or power to perform a designated
function

3.0. Sample type, Equipment and Materials/ Reagents/ Supplies

3.1. Equipment
N/A

3.2. Materials/ Reagents/Supplies

3.2.1. Quality Control Samples
3.2.2. External Quality Assurance samples
3.2.3. Laboratory Reagents

4.0. Responsibility
4.1. All EQA personnel given the responsibility to perform lot to lot validation and
parallel testing are responsible for the implementation of this procedure

5.0. Procedure
5.1. Clinical laboratory reagents and control materials are exposed to many variables
due to conditions during transportation and storage environments in different
laboratory settings. The validation of new reagent kits with old reagent kits is
performed to ensure that, in spite of varying environmental conditions, there are no
clinically significant differences in the results obtained when different lot numbers of
reagents are used
5.2. Control materials are parallel-tested to ensure that the mean of the values obtained
are within the ranges specified by each manufacturer. Where applicable, the data
gained during parallel testing should then be utilized to establish QC ranges for each
individual laboratory. The procedure outlines the parallel testing and reagent lot
validation testing required for different sections of EQA Laboratories

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 5.3. The Quality Control Parallel Testing:
5.3.1. Quantitative Assay Controls:
5.3.1.1. The new control lot number should be run in parallel with the old
lot number before it expires. In order to validate new controls, the
new lot of controls will be run in parallel with the old lot of
controls once a day for 3 days, to give a minimum of 3 values
5.3.1.2. If not possible to run the new controls in parallel with the old lot
of controls, then the new batch shall be run on 3 different days and
this reading shall be compared with previous readings obtained of
the old lot of controls
5.3.1.3. If the Values will be used to calculate laboratory specific QC
ranges a minimum of twenty runs is needed i.e. new controls are
run 2-3 times a day for 5-10 days, to give a minimum of 20 values
to enable the calculation of laboratory specific QC ranges
5.3.1.4. If 20 runs cannot be completed, a minimum of seven runs (three
replicates per run) may be used to set provisional ranges. A mean
and standard deviation will be calculated and used to set
provisional ranges. The mean and limits derived from the
abbreviated data collection should be replaced by a new mean and
limits calculated when data from 20 separate runs becomes
available
5.3.1.5. The laboratory in-charge or Designee should review and sign off
on the QC parallel testing data before the new lot of controls is put
into operation. This includes the mean, QC ranges and standard
deviation for the new lot of the controls. This will be done before
the new control is used
5.3.1.6. This is to enable the demonstration that the QC material is
performing as expected.

5.3.2. Semi-Quantitative Assay Controls:

5.3.2.1. Each new lot of QC for semi-quantitative assays must be
run and give an expected response (Manufacturer
specified Quality Control specifications or EQA Laboratory
pre- defined Quality Control specifications). The lot of controls
will be reviewed and signed off by the laboratory in-charge
or designee before being put into use

5.3.3. Qualitative Assay Quality Controls:

5.3.3.1. Each new lot of QC for qualitative assays must be run and
give an expected response (Manufacturer specified Quality
Control specifications or EQA Laboratory pre-defined
Quality Control specifications). The lot of controls will be
reviewed and signed off by the laboratory in-charge or
designee before being put into use

5.3.4. Data Collection (If required):

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 5.3.4.1. If any data collection is to be representative of future
system performance, sources of variation that are expected
and determined acceptable may be included during the data
collection period. Where applicable these may include:
5.3.4.1. Multiple stored calibrations
5.3.4.2. Multiple reagent lots
5.3.4.3. Multiple calibrator lots
5.3.4.4. Multiple bottles of control Material (especially
with lyophilized material)
5.3.4.5. Multiple operators
5.3.4.6. Data points collected at different times of day

5.3.4.1. Handling the data:

5.3.4.1.1. Determine the MEAN for each control parameter for
each control level

5.3.4.1.2. Determine the standard deviation (s) value from the

calculated MEAN

5.3.4.1.3. NOTE: s represents the standard deviation,    means

summation of all the (xi -  )2 values, xi is an individual
control result,  is the mean of the control results, and
n is the total number of control results included in the
group.
5.3.4.1.4. Eliminate any values that fall outside of ±3 SD of the
mean (these results may be due to poor sample
handling, etc.)
5.3.4.1.5. Recalculate the MEAN with the remaining values
5.3.4.1.6. Recalculate the standard deviation
5.3.4.1.7. Given the mean and standard deviation for a control
material, control limits are calculated as the mean plus
and minus a certain multiple of the standard deviation,
such as 2s or 3s

5.3.4.2. Should I use the manufacturer's control ranges or establish

my own?
5.3.4.2.1. The manufacturer's stated ranges give an indication of
where a customer's mean and ranges may be
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 established. The EQA Laboratories will use
manufacturers’ pre-set QC ranges to determine the
performance of their measurement system. Appropriate
mean and QC ranges will be established if the values
for the new lot of quality control material are moving
towards the manufacturers QC action limits or are
outside 1 SD of the manufacturers mean

5.4. Reagent lot validation:

5.4.1. Semi-Quantitative Assays:
5.4.1.1. A minimum of 3 patient samples (negative, low positive and high
positive if available) for semi-quantitative or Sample with known
results from previous run are tested in parallel with QC on both
the old and the new lot numbers
5.4.1.1.1. The QC and patient results should be reproducible
between the two lots (reproducibility includes both the
OD readings and the interpretations if it is an ELISA).
5.4.1.1.2. The Laboratory in-charge or designee is responsible for
defining acceptability limits for parallel testing
(Example: OD variance of 1SD or less and agreement
on the interpretation)

5.4.1.2. Quantitative Assays:

5.4.1.2.1. A minimum of 3 patient samples abnormally low,
normal and abnormally high from a previous run are
tested in parallel with the QC on both the old and the
new kit or reagent lot number
5.4.1.2.2. The QC and patient results should be reproducible
between the two lots
5.4.1.2.3. The Laboratory in-charge or designee is responsible for
defining acceptability limits for parallel testing (typical
criteria for the acceptability of Quantitative assays
would be that any variation should not be greater than
Total Error Allowable published by Competent
Authorities)

5.4.1.3. Qualitative Assays:

5.4.1.3.1. A minimum of 3 patient samples should be run in
parallel on both the old and the new lots
5.4.1.3.2. The QC and patient results should be reproducible
between the two lots
5.4.1.3.3. The Laboratory in-charge or designee reviews the
results and confirms that there is agreement between the
results for the two kits (i.e. negative results on the old
kit are negative on the new kit and positive results on
the old kit are positive on the new kit)
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 5.5. Documentation:
5.5.1. Documentation of reagent lot validation and Quality Control Parallel
testing shall be put down in the section’s lot to lot validation forms that
includes appropriate space for entering the following data:
5.5.1.1. Lot numbers (old and new lot numbers) and their expiry
dates
5.5.1.2. Results obtained from the old and new lots
5.5.1.3. Criteria for acceptance and space to indicate if the results
obtained on the new lots were acceptable
5.5.1.4. QC values on both runs (include QC lot numbers)
5.5.1.5. Space for the person completing the parallel testing to sign
and date the form and a place for a reviewer to sign and enter the
date
5.5.1.6. A place for recording equipment or method background
checks results

5.6. Quality Control:

5.6.1. The Laboratory in-charge or designee will do random Quality Control
checks to ensure that this SOP is implemented as written. If Quality
control checks reveal non-compliance to this SOP, the SOP deviations and
violations will be investigated, corrective and preventive action initiated,
implemented, reviewed and closed-out. All corrective and preventive
action should be documented in the corrective action form
5.6.2. Comparison studies must be performed before or at the same time that
new reagent lots are placed in service
5.6.3. Material of known value may include patient samples, control material,
External Quality Assurance material or certified reference materials
5.6.4. Background checks must be performed on inert materials such as diluent
to ensure that new lots do not interfere with patient results
5.6.5. Tests, certified reference materials, External Quality Assurance material
and quality Control materials for parallel testing and lot to lot validation
should cover the method reportable range.

5.7. Results
N/A

5.8. Reference values

N/A

5.9. Reporting
N/A
5.10. Limitations
N/A

5.11. Specimen Retention and Storage

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 N/A

6.0. Related Documents

6.1. Training Procedure ( )
6.2. Equipment Management procedure (EQA-LAB-SOP11)

7.0. References
7.1. Westat Checklist General required elements – Parallel Testing
7.2. Westgard website - www. Westgard.com
7.3. Mercy Medical Center –Baltimore, Maryland: Yearly Coagulation Lot
changes
7.4. Grove N., Rotzoll, K. CLIA Corner: Prothrombin Time and INR Testing. of
Iowa Hygienic Laboratory
8.0. Appendix
8.1. Chemistry Lot to lot and parallel testing forms (EQA-LAB-SOP14F1)
8.2. Hematology Lot to lot and parallel testing forms (EQA-LAB-SOP14F2)
8.3. Qualitative Reagent Lot to lot and parallel testing forms (EQA-LAB-SOP14F3)
8.4. EIA/Semi quantitative Lot to lot validation (EQA-LAB-SOP14F4)

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP15

Laboratory Department Authorized Use of Expired and Version: 1

Section: General Quality Expired On-board Reagents Copy No:
Effective Date:
1.0. Purpose/Applicability
1.1. Purpose
This Standard Operating Procedure establishes procedures for the use of expired
and expired on-board reagents at The Equity Afia Health Facilities’ Laboratories

1.2. Scope
This procedure applies to use of all Laboratory reagents which have expired within
EQA Laboratories. All the staffs within EQA Laboratories are required to comply
with this policy document when handling or using expired reagents or supplies.

1.3. Principle/Safety
1.3.1. Principle
N/A

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when
handling potentially infectious material and practice GCLP
(EQA-SAF-P004)

2.0. Abbreviation, Definitions and Terms

2.1. Abbreviations
2.1.7. EQA – Equity Afia Health care Facility
2.1.8. ISO – International Organization for Standardization
2.1.9. GCLP – Good Clinical Laboratory Practice
2.1.10. SOP – Standard Operating Procedure

2.2. Definitions and Terms

N/A

3.0. Equipment and Materials/ Reagent/ Supplies

N/A

4.0. Responsibility
4.1. All EQA personnel given the responsibility to perform sample testing are responsible
for the implementation of this procedure

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5.0. Procedure
5.1. It is the general policy NOT to use reagents that have expired, even though many
reagents are viable for periods longer than indicated on labels. However, due to
logistical problems associated with laboratories located in Kenya, it may become
necessary to use expired reagents for testing of patient samples. The expired
reagents must adhere to this policy

5.2. General Requirements of Expired Reagents

5.2.1. No expired reagents will be used in clinical tests that will result in
patient diagnosis or treatment unless authorized by the laboratory
in-charge
5.2.2. Expired reagents must be segregated from other reagents. They
may not be stored on the same shelf, in the same refrigerator or in
the same freezer as current reagents
5.2.3. If 5.2.2 is not possible, then these reagents shall be clearly marked
as expired or stored in a container within the same fridge that is
clearly marked “EXPIRED REAGENTS” and be removed from
the fridge as soon as supply of the reagent resumes
5.2.4. The shelf, refrigerator or freezer must be clearly identified as
containing expired reagents
5.2.5. A copy of all documentation required by this SOP must be located
within the laboratory and also within the storage area of the
reagents
5.3. Steps:
5.3.1. Document on the form – Authorization for Use of Expired
Reagents (EQA-LAB-SOP16F1)
5.3.2. Obtain approval for use of expired reagents from Laboratory in-
charge or designee. If the individual is not present for signature,
the test may not be performed until their return
5.3.3. Run controls and confirm that reagents/controls are within range.
Discontinue use of expired reagents when controls are out of
range.
5.3.4. When expired reagents or equipment past their service dates are
used, the Laboratory in-charge will carefully review the assay to
ensure that sensitivity, accuracy, and precision have not been
compromised, and record the results of those findings on the
Corrective action and Preventive Action Form. For equipment with
delayed service, IQC frequency shall be increased if not done daily
5.3.5. Levy Jennings charts will be monitored and stored ensuring that no
trends are forming in the performance of quality controls for the
tests using the expired reagents. The Levy Jennings charts will be
printed at the end of each month but reviewing of performance
shall be done weekly. And the Laboratory in-charge or designee
will ensure daily performance

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 5.3.6. The use of expired reagents will be discontinued upon availability
of replacement supplies

5.4. Reagents Expired on Board:

5.4.1. Reagents which have overstayed their lifetime in the equipment
and not expired as labeled by the manufacturer will be validated
before they are used to analyze patient samples. Validation will be
done as below:

5.4.1.1. Semi-Quantitative Assays:

5.4.1.1.1. A minimum of 3 patient samples (negative, low
positive and high positive if available) for semi-
quantitative or Samples with known results from the
non-expired and the expired reagents are tested in
parallel with the QC or Samples with known values on
both the non-expired and the expired reagents. The QC,
Samples with known values and patient results should
be reproducible between the non-expired and the
expired reagents. The Laboratory manager, Quality
officer or designated technologist is responsible for
defining acceptability limits for parallel testing

5.4.1.2. Quantitative Assays:

5.4.1.2.1. A minimum of 3 patient samples abnormally low,
normal and abnormally high from the non-expired and
the expired reagents are tested in parallel with the QC
or Samples with known values on both the non-expired
and the expired reagents. The QC, Samples with known
values and patient results should be reproducible
between the non-expired and the expired reagents. The
Laboratory manager, Quality Officer or designated
technologist is responsible for defining acceptability
limits for parallel testing (typical criteria for the
acceptability of Quantitative assays would be that any
variation should not be greater than Total Error
Allowable published by Competent Authorities)

5.4.1.3. Qualitative Assays:

5.4.1.3.1. A minimum of 3 patient samples should be run in
parallel with the QC or Samples with known values on
both the non-expired and the expired reagents.
5.4.1.3.2. The QC, Samples with known values and patient results
should be reproducible between the non-expired and the
expired reagents
5.4.1.3.3. The Laboratory in-charge or designee reviews the
results and confirms that there is agreement between the
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 results for the two kits (i.e. negative results are negative
on the new kit and positive results are positive).

5.5. Quality Control/Calibration

5.5.1. The Laboratory in-charge or designee will do random Quality
Control checks to ensure that this SOP is implemented as written.
If Quality control checks reveal non-compliance to this SOP, the
SOP deviations and violations will be investigated, corrective and
preventive action initiated, implemented, reviewed and closed-out.
All corrective and preventive action should be documented in the
corrective action form.

5.25. Results
N/A

5.26. Reference values

N/A

5.27. Reporting
N/A

5.28. Limitations
N/A

5.29. Specimen Retention and Storage

N/A

6.0. Related Documents

N/A

7.0. References
7.1. NCCLS Clinical Laboratory Technical Procedure Manuals, GP2-A2, 3rd Edition;
Approved Guideline, 1996
7.2. Basics of Quality Assurance for Intermediate ad Peripheral Laboratories, WHO
Regional Publications, Eastern Mediterranean Series No. 2, 1992

8.0. Appendix
8.1. Authorized use of expired and expired on-board reagents form (EQA-LAB-
SOP16F1)

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP16

Laboratory Department Version: 1

Section: General Quality Temperature Monitoring Copy No:
Effective Date:
1.1. Purpose/Applicability
1.2. Purpose
To ensure comprehensive and consistent temperature monitoring of Equity Afia
health facilities’ (EQA) Laboratory equipment such as water baths,
refrigerators, freezers, incubators and environment (ambient temperature)

1.3. Scope
This procedure is applicable to all sections of EQA Laboratory.

1.4. Principle & Safety

1.4.1. Principle
N/A

1.4.2. Safety
1.4.2.1. Always wear personal Protective Equipment when handling
potentially infectious materials
1.4.2.2. Thermometers pose a physical hazard when broken. Do not handle
broken thermometers by hand. Use a broom and dust pan only.
Clean all breakages using the appropriate PPE as designated in the
Laboratory Safety Manual
1.4.2.3. DO NOT use mercury thermometers. They pose a health hazard when
broken.

2.0. Abbreviations, Definitions and Terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia health facility
2.1.2. SOP- Standard Operating Procedure
2.1.3. NIST – National Institute of Standards and Technology
2.1.4. KEBS – Kenya Bureau of Standards certification body
2.1.5. UPS – Uninterruptible power supply
2.1.6. QMS – Quality Management System
2.1.7. PPE-Personal Protective Equipment

2.2. Definitions
N/A

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3.0. Sample type, Equipment and Materials/Reagents/Supplies
3.1. Sample type
N/A

3.2. Equipment
3.2.1. Digital thermometers
3.2.2. Certified NIST/KEBS Calibrated thermometer
3.2.3. Freezers
3.2.4. Refrigerators
3.2.5. Water Baths
3.2.6. Incubators

3.3. Materials/ Reagents/ Supplies

N/A

4.0. Responsibilities
4.1. All EQA Laboratory personnel are responsible for the implementation of this
procedure
4.1.1. Individual responsibilities are defined in 5.0

5.0. Procedure
5.1. Temperature Recording
Responsible staff: section technical staff
5.2. All temperature sensitive equipment must be monitored
5.3. All the above equipment should have temperature recording logs. Logs
contain the following information:
5.3.1. Name of temperature controlled device
5.3.2. Model
5.3.3. Serial Number
5.3.4. Range
5.3.5. Location
5.3.6. Month/Year
5.3.7. Day of the month
5.3.8. Temperature reading
5.3.9. Tech initials
5.3.10. Thermometer number
5.4. Temperatures must be recorded at least TWICE per day and recorded on the
corresponding log with weekends and holidays included
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 5.5. Any readings which fall outside the demarcated tolerance/safety regions must be
reported to the person in-charge at the time who in turn calls the service technician
5.6. This occurrence is logged in the section occurrence register with a record of the
corrective action taken
5.7. Immediate action or correction taken to mitigate the situation:

If Then
Refrigerator cannot be repaired or Remove stored items to another controlled
temperature corrected within 60 minutes refrigerator of desired temperature
Freezer cannot be repaired or Remove stored items to another controlled
temperature corrected within 30 minutes freezer of desired temperature

5.8. Ambient/room temperature must be monitored with the use of a thermometer

mounted on the wall
5.9. The ambient temperature must be recorded at least TWICE per day and documented
on the temperature log sheet (EQA-LAB-SOP17F1)with weekends and holidays
included if facility operates on these days
5.10. If the temperature is out of range, then log a fault, originate a nonconformity and
process it
5.11. All temperature dependent equipment power sources are monitored and have a
system in place for outages i.e. UPS and Power generator back up
5.12. In the event that the temperature reading is outside the permitted range and the
problem cannot be rectified immediately, it is the responsibility of the recording
laboratory personnel to report this and any other findings to the Laboratory in-charge
or designee immediately
5.13. Corrective action Report should be completed and should include:
5.13.1. Piece of equipment affected
5.13.2. Items removed/transferred if applicable
5.13.3. New location of items moved
5.13.4. Date and time of the problem
5.13.5. Date and time of the action taken
5.13.6. Date and time the Lab Manager/nominee was notified
5.13.7. Final Resolution of problem
5.13.8. Initials of staff member taking action
5.14. The Laboratory in-charge in discussion with the section staff and facility
maintenance engineers shall assess the reported nonconformity and search for the
possible causes

5.15. Quality Control:

Responsible staff: Laboratory in-charge
5.15.1. All the thermometers used for temperature monitoring should be
calibrated against a certified NIST/KEBS traceable thermometer once per
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 year, after maintenance or malfunction. This is to ensure the thermometers
used in procedures, water baths, incubators, refrigerators and freezers are
accurate when compared to a NIST or KEBS traceable thermometer
5.15.2. All temperature log sheets should be reviewed by in-charge bi-monthly
All out of range and corrective actions should be documented

5.16. Expected Values:

5.16.1. All ranges for the different equipment have been indicated in the different
temperature log sheets as indicated below:

Instrument Expected Range ◦C

Blood Bank Water bath +35◦C to 38◦C
Media room Water bath + 54°C to 58°C
Refrigerator + 2◦C to 8◦C
Freezer ( -20 ◦C) -12◦C to -25◦C
Freezer (-80 ◦C) -70◦C to -90◦C
Room Temperature +19◦C to 25◦C
Microbiology Incubator +35◦C to 37◦C
Histology Incubator +56°C to 60°C

5.17. Archiving Results and Report Documents

Responsible staff: Section technical staff
5.17.1. All Thermometer Calibration Verification Record sheets should remain on
file as a record in the particular department even after the thermometer has
been removed permanently from service
5.17.2. All Temperature Monitoring log sheets should be kept on file while
equipment is in service and archived as per laboratory records
management SOP

6.0. Related Documents

6.1. Management of nonconformity ( )
6.2. Records management SOP ( )

7.0. References
7.1. ISO 15189:2007
7.2. Clinical Laboratory Standards Institute (CLSI). Clinical Laboratory Technical
Procedure Manuals; Fourth Edition. CLSI Document GP2-A4 (ISBN 1-56238-
458-9). Clinical and Laboratory Standards Institute, Wayne, PA

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8.0. Appendix
8.1. Room Temperature Monitoring sheet (EQA-LAB-SOP17F1)
8.2. Fridge Temperature Monitoring sheet (EQA-LAB-SOP17F2)
8.3. Incubator/water bath Temperature Monitoring sheet (EQA-LAB-SOP17F3)
8.4. Freezer Temperature Monitoring sheet (EQA-LAB-SOP17F4)
8.5. Water bath Temperature Monitoring sheet (EQA-LAB-SOP17F5)
8.6. Freezer Temperature Monitoring sheet (EQA-LAB-SOP17F6)
8.7. Document Distribution list ( )

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 HAEMATOLOGY/IMMUNOHAEMATOLOGY

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP17

Laboratory Department Version: 1

Section: Hematology Malaria Detection Copy No:
Effective Date:
1.0. Purpose/Applicability
1.1. Purpose
To describe the steps for performing the whole blood rapid test for qualitative
detections of circulating antigen of Plasmodium falciparum, Plasmodium ovale and/or
Plasmodium malariae

1.2. Scope
This procedure applies to the Hematology section at Equity Afia Health facilities’
laboratories

1.3. Principle & Safety

1.3.1. Principle
The Malaria P.f/pan rapid test device (whole blood) is a qualitative
membrane based immunoassay for the detection of P.f, P.v, P.o and P.m
antigens in the whole blood. To serve as a procedure control, a coloured line
will always appear in the control line region indicating that proper volume
of blood has been added and membrane wicking has occurred.

1.3.2. Safety
Always wear personal protective equipment when handling potentially
infectious material and practice GCLP

2.0. Abbreviation, definitions and terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia Health care Facility
2.1.2. GCLP – Good clinical laboratory practice
2.1.3. SOP- Standard Operating Procedure
2.1.4. Pf – Plasmodium falciparum
2.1.5. Pv – Plasmodium vivax
2.1.6. Po – Plasmodium ovale
2.1.7. Pm – Plasmodium malaria
2.1.8. ul -microlitre

2.2. Definitions and terms

N/A
3.0. Sample type, equipment and materials/reagents/supplies
3.1. Sample type
3.1.1. EDTA whole blood

3.2. Equipment
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 N/A
3.3. Materials/reagents/supplies
3.3.1. Disposable droppers
3.3.2. Test devices
3.3.3. Pipette
3.3.4. Timer
3.3.5. Buffer

4.0. Responsibility

5.0. Procedure
5.1. Allow the test device and specimen buffer to equilibrate to room temperature if
stored at 2 – 8 0C
5.2. Remove the test device from the foil pouch and use it as soon as possible.
Perform the test within one hour after removing the test device from the foil pouch
5.3. Place the test device on the clean and level surface of the bench
5.4. Transfer the specimen by a pipette or a dropper
5.5. To use a pipette. Transfer 10ul of whole blood to well – 1 (W1) of the test device,
then add 3 full drops of buffer to well – 2 (W2) and start the timer. Avoid trapping air
bubbles in W1
5.6. At the end of 5 minutes, add 1 full drop of buffer to W1
5.7. To use a disposable specimen dropper, hold the dropper vertically draw the
specimen up to the fill line and transfer the specimen to well 1 (W1) of the test device
5.8. Add 3 full drops of buffer to well 2 (W2) avoiding trapping air bubbles in W1 and
start the timer
At the end of 5 minutes, add 1 full drop of buffer to W1
Wait for coloured line(s) to appear
Read the results at 15 minutes. Do not interpret the result after 20min
5.9. Results
5.9.1. P.falciparum or mixed malaria
One line appears in the control region, one line appears in pan line region and one line
appears in P.f line region
5.9.2. P. falciparum infection
5.9.2.1. One line appears in the control region and one line appears in P.f
line region Non-falciparum plasmodium species infection
5.9.2.2. One line appears in the control region and one appears in P.f line
region
5.10. Reporting
5.10.1. When a line appears in the control region and any of the P.f/pan lines the
test is reported as “positive”
5.10.2. When a line appears in the control region and no line appears in the
P.f/pan regions, the test is reported as “negative”
5.10.3. If no line appears in the control region the test is invalid and should be
repeated
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 5.10.4. The patients final report is reported on HMIS
5.10.5. The report is dispatched as per the procedure for reporting and release of
results
5.11. Specimen retention
5.11.1. Testing should be performed immediately after specimen collection. Do
not leave the specimens at room temperature for prolonged periods
5.11.2. Store at 2 - 8°C if test is to be run within 2 days of collection
5.12. Limitations
5.12.1. The malaria pf/pan rapid test device (whole blood will only indicate the
presence of antigens of plasmodium species. (P.f, P.v, P.o, P.m) in the
specimen and should not be used as the sole criterion for the diagnosis of
malaria infection
5.12.2. As with all diagnostic tests, all results must be interpreted together with
other clinical information available to physician.
5.12.3. If the result is negative and clinical symptoms persist, additional testing
using other clinical methods is recommended. A negative result does not
at any time preclude the possibility of malaria infection.

6.0. Related procedures/documents

6.1. Reporting and release of results (EQA-LAB-SOP38)

7.0. References
7.1. General diagnostic test kit insert

8.0. Appendix
N/A

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP18

Laboratory Department Version: 1

Section: Hematology Full Blood Count on ----------Machine Copy No:
Effective Date:
To be written once equipment is supplied

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP20

Laboratory Department Version: 1

Section: Hematology Bleeding Time Test Copy No:
Effective Date:
1.0. Purpose /Applicability
1.1. Purpose
To describe the steps for performing bleeding time as a measure of capillary function,
platelet numbers and ability of platelets to adhere to the vessel wall and to each other
to form a plug

1.2. Scope
This procedure applies to all patients requiring the bleeding test at the Haematology
section in the Equity Afia Health facilities Laboratories.

1.3. Principle & Safety

1.3.1. Principle
A small puncture is made in a standard way through the skin and the time
taken for the puncture to stop bleeding is measured carefully
1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviations, definitions and terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia
2.1.2. SOP - Standard Operating Procedure
2.1.3. RBC – Red blood cells
2.1.4. mmHg - Pressure
2.1.5. GCLP –Good Clinical Laboratory Practice

2.2. Definitions and terms

N/A

3.0. Sample type, equipment and materials/reagents/supplies

3.1. Sample type
3.1.1. Capillary blood

3.2. Equipment
3.2.1. Sphygmomanometer cuff

3.3. Materials/reagents/supplies
3.3.1. Stop watch
3.3.2. Disposable lancet
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 3.3.3. Filter paper
3.3.4. 70% ethanol

4.0. Responsibility

5.0. Procedure
5.1. Place a sphygmomanometer cuff around the patient’s arm above his elbow
5.2. Inflate the pressure to 40 mm Hg throughout the test
5.3. Clean/sterilize the volor surface of the forearm with70% ethanol
5.4. Using a disposable lancet, make 2 precise and tentative jabs, 5-10 cm apart
5.5. A disposable lancet which has a cutting depth of 2.5 mm and width just over 1
mm is suitable
5.6. Blot off the blood exuding from each puncture gently but completely at 15
seconds intervals using the filter paper
5.7. Record the bleeding times of the two punctures
5.8. The longer of the duplicate bleeding times is a more accurate assessment of the
test than the average of the two
5.9. Results
5.9.1. Normal reference range : 2 - 7 minutes
5.10. Reporting
5.10.1. The patient’s final report is reported on the HMIS
5.10.2. The report is dispatched as per the procedure for reporting and release of
results (EQA-GSP-P008)
5.11. Limitations
5.11.1. Puncturing of superficial veins may occur in people with thin skins

5.12. Specimen retention and Storage

N/A

6.0. Related procedures/documents

N/A

7.0. References
7.1. Practical Hematology by J.V Dade and S.M Lewis, Fifth Edition

8.0. Appendix
N/A

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP20

Laboratory Department Version: 1

Section: Hematology Sickle Cell Test Copy No:
Effective Date:
1.0. Purpose /Applicability
1.1. Purpose
To describe the steps for performing sickle cell slide test

1.2. Scope
This procedure applies to all blood samples requiring sickling test or suspected sickle
cell patients in the Hematology section at Equity Afia healthcare facilities’
laboratories

1.3. Principle & Safety

1.3.1. Principle
When blood is mixed on a slide with a chemical reducing agent such as
sodium metabisulphite, cover slipped and incubated at room temperature
for up to an hour or more, the reducing agent deoxygenates the
haemoglobin in the red cells providing the conditions for cells containing
Haemoglobin S(Hb S) to sickle

1.3.2. Safety
1.3.2.1. Exercise care when using glass slides which may break,
possibly causing injury and exposure
1.3.2.2. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviations, definitions and terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia
2.1.2. SOP - Standard Operating Procedure
2.1.3. RBC – Red blood cells
2.1.4. mmHg - Pressure
2.1.5. GCLP –Good Clinical Laboratory Practice
2.1.6. EDTA – Ethylene Diamine Tetra Acetic acid
2.1.7. Hb S-Haemoglobin S

2.2. Definitions and terms

N/A

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3.0. Sample type, equipment and materials/reagents/supplies
3.1. Sample type
3.1.1. EDTA blood

3.2. Equipment
3.2.1. Microscope
3.2.2. Weighing balance
3.2.3. Roller mixer
3.2.4. Incubator set at 37°C

3.3. Materials/reagents/supplies
3.3.1. Sodium metabisulphite
3.3.2. Clean microscope slides
3.3.3. Cover glasses
3.3.4. Pipettes
3.3.5. Bottle of 15ml capacity
3.3.6. Distilled water
3.3.7. Petri dish
3.3.8. Damp blotting paper
3.3.9. Marker
3.3.10. Pipette tips

4.0. Responsibility

5.0. Procedure
5.1. Preparation of reducing reagent:
5.1.1. Weigh 0.2g of sodium metabisulphite and transfer to a bottle of 15ml
capacity
5.1.2 Add 10ml of distilled water, stopper and mix until the chemical is fully
dissolved.
5.1.3 The chemical is unstable. It can be used only on the day it is prepared( up
to 8 hrs)
5.1.4 Using a marker label the container the time of preparation, expiration date
and technologist who prepared.
5.2. Procedure for slide test
5.2.1. Compare the patient name on the received request form with the name on
the Sample
5.2.2. Ensure the blood is thoroughly mixed on the roller and by rotating it
between the fingers and or by gentle inversion
5.2.3. Deliver one drop of patients’ blood on a slide marked with the patients lab
reference number
5.2.4. Add an equal volume of fresh reducing agent, mix and cover with a cover
glass excluding any air bubble

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 5.2.5. Set up a negative control by delivering one drop of blood from a known
normal sample and treat it as the test sample. Label the slide Negative
control
5.2.6. Add equal volumes of fresh reducing agent and mix. Cover with a cover
glass excluding any air bubbles
5.2.7. If blood from a known sickle cell trait is available, set up a positive
control
5.2.8. Place the slides in a Petri dish with a damp piece of blotting paper or
tissue in the bottom to prevent drying of the preparations
5.2.9. Close the Petri dish and leave it at room temperature
5.2.10. After 10-20 minutes examine the patient preparations microscopically for
sickle cells
5.2.11. Use the X10 objective to focus and examine for sickling using the X40
objective
5.2.12. If preparation is negative, incubate the Petri dish in an incubator at 37˚ C
for 1-2hours and examine like in 5.2.10 and 5.2.11
5.2.13. If still negative, return the preparation to the incubator and examine after
18-24hours incubation at 37˚ C
5.3. Results
5.3.1. Positive sickle cells may appear crescent-shaped with pointed ends or
holly leaf shaped especially in sickle cell trait
5.4. Reference ranges
N/A
5.5. Reporting
5.5.1. Report the patient’s preparation as sickle cell test “Positive” if a positive
result is obtained or sickle cell test “Negative” if a negative result
is obtained as shown in 5.3. above
5.5.2. The patient’s final report is reported on HMIS as per the procedure for
reporting and release of results
5.6. Limitation
5.6.1. Sickle cell slide test is simple to perform since it requires only a single
reagent but does not differentiate between sickle cell disease and sickle
cell trait
5.7. Sample storage and Retention
5.7.1. Store the specimen as per the specimen retention and storage procedure

6.0. Related procedures/documents

6.1. Reporting and release of results (EQA-LAB-SOP38)

7.0. References
7.1. District laboratory practice for Tropical countries by Monica Cheeseborough

8.0. Appendix
N/A

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP20

Laboratory Department Version: 1

Section: Hematology Erythrocyte Sedimentation (ESR)Test Copy No:
Effective Date:
1.0. Purpose /Applicability
1.1. Purpose
To describe the steps for performing Erythrocyte Sedimentation Rate (ESR) test using
the wintrobe tube method

1.2. Scope
This procedure applies to all blood samples requiring ESR test in the Hematology
section at Equity Afia healthcare facilities’ laboratories

1.3. Principle & Safety

1.3.1. Principle
Citrated blood in a vertically positioned wintrobe tube if left undisturbed,
RBCs aggregate and stack together to form rouleax and sediment
through then plasma. ESR is the rate at which this
sedimentation occurs in one hour as indicated by the
length of the column of clear plasma above the RBCs
measured in mm.

1.3.2. Safety
1.3.2.1. Exercise care when using glass slides which may break,
possibly causing injury and exposure
1.3.2.2. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviations, definitions and terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia
2.1.2. ESR – Erythrocyte Sedimentation Rate
2.1.3. RBC – Red blood cells
2.1.4. CBC – Complete blood count
2.1.5. EDTA - Ethylene Diamine Tetra Acetic acid
2.1.6. GCLP – Good clinical laboratory practice
2.1.7. HMIS- Health Management Information System
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 2.2. Definitions and terms
N/A

3.0. Sample type, equipment and materials/reagents/supplies

3.1. Sample type
3.1.1. EDTA whole blood

3.2. Equipment
3.2.1. Roller mixer

3.3. Materials/reagents/supplies
3.3.1. ESR wintrobe tube
8.1.1. ESR stand
8.1.2. Pasteur pipette (long tip)
8.1.3. Timer

4.0. Responsibility

5.0. Procedure
5.1. Compare the patient name on the received request form with the name on the
sample
5.2. Ensure the blood is thoroughly mixed on the roller and by rotating it
between the
fingers and/or by gentle inversion
5.3. Check that the ESR stand is level and stable on the ESR bench
5.4. Using a pipette, draw from the specimen vacutainer and dispense into
the wintrobe
tube to the 0 mark
5.5. Carefully and gently place the wintrobe tube into the ESR stand ensuring
that the
the test is not exposed to direct sunlight
5.6. Immediately set the timer for one hour
5.7. Record the ESR test information in the ESR chart (EQA-LAB-P020F1)
5.8. After exactly one hour, read the level at which the plasma meets the red
cells in mm. Record this in the ESR chart
5.9. After reading the ESR, remove the tubes carefully from the stand and
soak them in
sodium hypochlorite solution (0.25%) placed in a container on the ESR bench
5.10. Results
5.10.1. ESR is a screening test
5.10.2. Normal reference ranges:

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 Group Normal reference range
Men 0 – 9 mm
Women and Children 0 – 20 mm
5.11. Reporting
5.11.1. The patient’s final report is reported on the HMIS
5.11.2. The report is dispatched as per the procedure for reporting and release of
results (EQA-GSP-P008)
5.12. Limitations
5.12.1. Because of many factors that affect red cell sedimentation, slightly and
moderately raised values may not be significant particularly in tropical
countries
5.12.2. Markedly raised values should be investigated

5.13. Sample retention and storage

5.13.1. Store the specimen as per the specimen retention and storage procedure

6.0. Related procedures/documents

6.1. Reporting and release of results (EQA-LAB-SOP38)

7.0. References
7.1. District laboratory practice for Tropical countries by Monica Cheeseborough part
2

8.0. Appendix
8.1. ESR Chart (EQA-LAB-SOP020F1)

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 BIOCHEMISTRY (To be done once equipment is supplied)

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 SEROLOGY

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP28

Laboratory Department Version: 1

Section: Serology Pregnancy Detection Test (PDT) Copy No:
Effective Date:
1.0. Purpose/Applicability
1.1. Purpose
To describe the steps for performing one step pregnancy test to aid in early detection
of pregnancy / gestation

1.2. Scope
This procedure applies to the Serology section at the Equity Afia Health facilities’
Laboratories

1.3. Principle & Safety

1.3.1. Principle
One step PDT is a rapid chromatographic immunoassay for qualitative
detection of HCG. The test utilizes combination of antibodies including
monoclonal HCG antibody to selectively detect presence/elevated levels of
HCH. The specimen migrates on the strip via capillary action to react with
coloured conjugate. Positive specimens react with the specific antibody –
hcG-coloured conjugate to form a coloured line at the test region of
membrane. Absence of this coloured line suggests negative results. To serve
as a procedural control, a colored line will always appear in the control line
region indicating that proper volume of specimen has been added and
membrane wicking has occured

1.3.2. Safety
Always wear personal protective equipment when handling potentially
Infectious material and practice GCLP

2.0. Abbreviation, definitions and terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia Health care Facility
2.1.2. GCLP – Good clinical laboratory practice
2.1.3. SOP- Standard Operating Procedure
2.1.4. PDT – Pregnancy Detection Test
2.1.5. HCG – Human Chorionic Gonadotropin

2.2. Definitions and terms

N/A

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3.0. Sample type, equipment and materials/reagents/supplies
3.1. Sample type
3.1.1. Urine

3.2. Equipment
N/A
3.3. Materials/reagents/supplies
3.3.1. Timers
3.3.2. PDT strips

4.0. Responsibility
4.1.

5.0. Procedure
5.1. Ensure that the patient’s name on the request form corresponds with the labeling
on the patient’s sample. Use microbiology work sheets to report the sample finding
after analysis
5.2. Bring the strip to room temperature before using it by placing it; unopened on the
bench for a few minutes
5.3. Remove the test strip from the sealed pouch
5.4. Hold the strip with the arrows drawn on it pointed toward the urine specimen
5.5. Open the urine container and immerse the test strip for 10 to 15 seconds
5.6. Avoid immersing the test strip into the urine past the marked maximum line on
the strip
5.7. Place the strip on a non-absorbent flat surface and leave it for 5 minutes for
the reaction to take place

5.8. Results
Results Observation
Positive test Two distinct pink-red lines appear on test region (T)
and control region (C)
Negative Test One pink – red line appears in the control region ©.
No colored line appears at region “T”
Invalid Test Control line “C” fails to appear
5.9. Reporting
5.9.1. Report the results as pregnancy test positive or as pregnancy test negative
as per observations interpreted in 5.8.
5.9.2. The patient’s final report is reported on the HMIS
5.9.3. The report is printed and a copy dispatched as per the procedure for
reporting and release of results
5.10. Specimen Retention and storage
5.10.1. If analysis is not done immediately, store the sample at 2-8° for 18 -24
hours

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 5.11. Limitations
5.11.1. False positive results are produced in conditions such as trophoblastic
diseases, testicular tumors and prostate cancer
5.11.2. Very low levels of HCG (less than 50 m/u/ml) are present in a urine
sample shortly after implantation therefore weakly positive results should
be confirmed by repeating the test with first morning urine 48 hours later

6.0. Related procedures/documents

6.1. Reporting and release of results (EQA-LAB-SOP38)

7.0. References
7.1. Diaspot HCG/PDT kit insert

8.0. Appendix
N/A

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP29

Laboratory Department Version: 1

Section: Serology Antistreptolysin – O (ASO) Test Copy No:
Effective Date:
1.0. Purpose/Applicability
1.1. Purpose
To describe the steps for performing antistreptolysin – O (ASO) test.
ASOT rapid test is for qualitative and quantitative estimation of antistreptolysin-O in
human serum

1.2. Scope
This procedure applies to the Serology section at Equity Afia Health facilities’
laboratories

1.3. Principle & Safety

1.3.1. Principle
The ASO reagent is a suspension of polystyrene latex particles coated with
stabilized Streptolysin O. The reagent has been adjusted in the way that the
presence of an ASO titer of 200IU/ml or higher in the serum gives a visible
agglutination of the latex particles without previous sample dilution

1.3.2. Safety
Always wear personal protective equipment when handling potentially
infectious material and practice GCLP

2.0. Abbreviation, definitions and terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia Health care Facility
2.1.2. GCLP – Good clinical laboratory practice
2.1.3. SOP- Standard Operating Procedure
2.1.4. Abs - Antibodies
2.1.5. Ags – Antigens
2.1.6. ASOT - Antistreptolysin-O test
2.1.7. IgG - Immunoglobulin
2.1.8. ul -microlitre

2.2. Definitions and terms

N/A

3.0. Sample type, equipment and materials/reagents/supplies

3.1. Sample type
3.1.1. Human serum

3.2. Equipment
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 3.2.1. Rotator

3.3. Materials/reagents/supplies
3.3.1. 10 - 100ul pipette with disposable tip
3.3.2. Gloves
3.3.3. Stirrer
3.3.4. Small glass or plastic
3.3.5. Reusable agglutination slide

4.0. Responsibility

5.0. Procedure
5.1. Ensure that the patient’s name on the request form corresponds with the labeling on
the patient’s sample. Record the sample on the Serology worksheet
5.2. Remove the ASO-Latex reagent from the reagent fridge and allow each component
to reach room temperature (5-10 minutes)
5.3. Gently shake the latex reagent to disperse the particles
5.4. Place a drop of undiluted serum using the sample pipettes provided in the kit or,
using the disposable tips pipette, measure 50ul and place onto the circle of the test
slide
5.5. Add a drop of the latex reagent next to the drop of serum
5.6. Spread the reagent and serum sample over the entire area of the test circle using a
stirrer
5.7. Place the test slide on the rotator and switch it on to gently tilt the slide backwards
and forwards for two minutes
5.8. Observe the presence of any observable agglutination in the reaction mixture
5.9. Quality Control
5.9.1. All reagents should be within the expiry date indicated by the
manufacturer
5.9.2. Positive and negative control reagents are included in the kit
5.9.3. 50ul of each of the control reagents is treated as the patient sample (steps
5.4 to 5.8
5.9.4. The positive control should have agglutinations (latex particles clumping
together) within 2 minutes while the negative control should have a
uniform milky suspension with no agglutination or clumping within 2
minutes
5.9.5. The controls are run weekly and when a new kit/new batch is opened to
monitor the method/reagent performance
5.9.6. The controls can also be run as a comparative pattern for a better result
comparison
5.10. Results
Result Observation
Positive Visible agglutination or clumping of latex particles
Negative No agglutination or clumping of latex particles
All positive results should further be titrated using serum dilutions

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 5.11. Semi-quantitative determination
5.11.1. The semi –quantitative test can be performed in the same way as the
qualitative test using dilutions of the serum in saline or phosphate buffered
saline as follow:-
Dilutions 1/2 1/4 1/8 1/32
Sample serum 100ul
saline 100ul 100ul 100ul 100ul
100ul
100ul
100ul
Volume of the sample 50ul 50ul 50ul 50ul
5.11.2. Interpretation
5.11.2.1. The titer of the serum is the reciprocal of the highest dilution
that exhibits a positive reaction.
5.11.2.2. Concentration will be reciprocal of positive reading dilution
X 200
200 x n˚of dilution 200 x 2 200 x 4 200 x 8 200 x 32
IU/ml 400 800 1600 6400
5.11.3. Normal Ranges/ Levels
5.11.3.1. <200 IU/ml

5.12. Reporting
5.12.1. When no agglutination is visible, report the test as ASOT negative
5.12.2. When agglutination appears, the test is positive and the dilution at which
agglutination was last observed should be reported in titers
5.12.3. The patient’s final report is reported on the HMIS ASOT template
5.12.4. The report is dispatched as per the procedure for reporting and release of
results

5.13. Limitations
5.13.1. The incidence of false positive is about 3 – 5 %.
5.13.2. False positive results may be obtained in conditions such as; rheumatoid
arthritis, scarlet fever, tonsillitis, several streptococcal infections and
healthy carriers
5.13.3. Contaminated sera and a longer reaction time (>3 minutes) may cause
false positive agglutination
5.13.4. Early infections and children from 6 months to 2 years may cause false
negative results

5.14. Specimen Retention and storage

5.14.1. If analysis is not done immediately, store the sample in refrigerator #2
at 2-8˚C. The test should be performed within 3 days of sample
collection

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6.0. Related procedures/documents
6.1. Reporting and release of results (EQA-LAB-SOP38)

7.0. References
7.1. Cypress Diagnostics ASO-Latex Slide agglutination kit insert

8.0. Appendix
N/A

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 MICROBIOLOGY

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP30

Laboratory Department Version: 1

Section: Microbiology Gram Staining Method for Bacteria Copy No:
Effective Date:
1.0. Purpose /Applicability
1.1. Purpose
To describe the steps for performing the Gram stain method for the staining,
demonstration and classification of bacteria

1.2. Scope
This procedure applies to the Microbiology section at the Equity Afia Health
facilities’
Laboratories

1.3. Principle & Safety

1.3.1. Principle
When bacteria cells are stained with crystal violet, and treated with iodine as the mordant, the
dye-iodine complex is easily removed (decolourized by acetone) from the more permeable
cell wall of gram negative bacteria but not from the less permeable cell wall of gram positive
bacteria. The gram positive bacteria also retain the crystal violet due to the acidity of their
protoplasm binding to the basic dye and thus stain purple in colour. The gram negative
bacteria then take up the counter stain neutral red.

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviations, definitions and terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia
2.1.2. QC – Quality Control
2.1.3. GCLP – Good clinical laboratory practice
2.1.4. HMIS- Health Management Information System

2.2. Definitions and terms

2.2.1. Cocci – Round or oval bacteria measuring about 0.5 – 1.0 um in diameter
2.2.2. Diplococci – Cocci in pairs

3.0. Sample type, equipment and materials/reagents/supplies

3.1. Sample type
3.1.1. Colony from inoculated plate
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 3.1.2. Pus or pus swab
3.1.3. Sputum
3.1.4. Trachael aspirate
3.1.5. CSF
3.1.6. Swabs e.g. HVS, urethral swab
3.1.7. Broth from inoculated liquid media

3.2. Equipment
3.2.1. Microscope
3.2.2. Bunsen burner

3.3. Materials/reagents/supplies
3.3.1 Clean glass slides – preferably frosted for easy labeling
3.3.2 Applicator stick or sterile wire loop
3.3.3 Staining rack
3.3.4 Draining rack
3.3.5 Oil Immersion
3.3.6 Clean water in wash bottles or tap water
3.3.7 Tissue paper/ paper towels
3.3.8 Crystal Violet stain
3.3.9 Lugol’s iodine
3.3.10 Acetone
3.3.11 Neutral red
3.3.12 Marker pen
3.3.13 Normal saline

4.0. Responsibility
4.1. The laboratory in-charge is responsible for the implementation of this
procedure
4.2. All technologists authorized to work in EQA laboratories are responsible for
the implementation of this procedure

5.0. Procedure
5.1. Prepare a smear of the specimen:
5.1.1. Label a clean slide with patient culture serial number
5.1.2. Place a drop of normal saline at the center of the slide
5.1.3. For inoculated colony plate using sterile wire loop or applicator stick, pick
a single colony or loop full of broth and emulsify on the drop of the saline
5.1.3. For pathological swab or material make a smear directly on the slide.
5.1.4. For CSF and other body fluids, centrifuge at 3000rpm for 3 minute pour
the supernatant, tap the bottom of the centrifuge tube to dislodge the
deposit and make a 2/3 size smear on the slide
5.1.5. Air dry the slide or pass the slide beneath a Bunsen burner flame gently
three to four times to dry the smear
5.2. Place the staining rack over the sink and place the slide on the rack
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 5.3. Cover the smear with crystal violet for 1 minute
5.4. Rapidly wash off the stain with clean water
5.5. Tip off all the water, and cover the smear with Lugol’s iodine for one minute
5.6. Wash off the iodine with clean water
5.7. Decolorize rapidly (10 seconds) with acetone. Avoid over decolourization
5.8. Counterstain by covering the smear with neutral red stain for 1 minute
5.9. Wash off the stain with clean water
5.10. Wipe the back of the slide with tissue paper to remove excessive stains
5.11. Place the slide in a draining rack for the smear to air-dry
5.12. Examine the slide with X100 (oil immersion) objective
5.13. Follow procedure 5.2 to 5.12 and set positive control using gram positive known
organisms slide smear and negative control using known gram negative
organisms slide smear

5.14. Results
Organism Appearance
Gram positive cocci Purple round/oval bacteria single, diplococci, in
chains or clusters
Gram positive rods purple stick – like bacteria either straight or curved
Gram negative cocci Pink round/oval bacteria mostly found as diplococci
Gram negative rods Pink stick – like bacteria either straight or curved
Background materials and pus cells Pink
Yeast cells Purple in round /oval form

5.15. QC Results
5.15.1. Positive control - Gram positive cocci in clusters seen
5.15.2. Negative control- Gram negative rods seen
5.16. Reporting
5.16.1. Depending on what is observed as indicated in the table in 5.14, Report
the
slide as:
5.16.1.1. Gram positive cocci in single, diplococci, chain or clusters seen
5.16.1.2. Gram positive rods seen
5.16.1.3. Gram Negative cocci in single, diplococci,
5.16.1.4. Gram negative rods seen
5.16.1.5. The patients final report is reported on the lifeline
5.16.1.6. The report is dispatched as per the procedure for reporting
and release of results
5.17. Specimen Retention and storage
5.17.1. If analysis is not done immediately, store the sample at 2°- 8° C and
perform the tests within 24 hours of collection
5.18. Limitations
N/A

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6.0. Related procedures/documents
6.1. Reporting and release of results (EQA-LAB-SOP38)

7.0. References
7.1. Practical Laboratory Manual for Health Centres in Eastern Africa by
Jane
Cartel and Orgencs Lema
7.2. Seventh Edition Baker and Silverston’s Introduction to Medical
Laboratory
Technology by Baker and Silvertons
7.3. District laboratory practice for Tropical countries by Monica
Cheeseborough

8.0. Appendix
N/A

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP31

Laboratory Department Version: 1

Section: Microbiology Ziel Nielsen Method for Staining Copy No:
Effective Date:

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP32

Laboratory Department Version: 1

Section: Microbiology Urine Analysis Copy No:
Effective Date:
1.0. Purpose /Applicability
1.1. Purpose
To describe the steps for performing urine analysis to aid in diagnosis of urinary
tract infections and other metabolic diseases in the body

1.1. Scope
This procedure applies to the Microbiology section at the Equity Afia Health
facilities’
Laboratories

1.2. Principle & Safety

1.1.1. Principle
Appearance of urine, turbidity and form is observed prior to chemical and
microscopic examination of centrifuged urine for detection of U.T.I’s and
other metabolic diseases in the body.

1.1.2. Safety
1.1.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviations, definitions and terms

1.3. Abbreviations
2.1.1. EQA – Equity Afia
2.1.2. QC – Quality Control
2.1.3. GCLP – Good clinical laboratory practice
2.1.4. HMIS- Health Management Information System
2.1.5. U.T.I - Urinary Tract Infections

1.4. Definitions and terms

N/A

3.0. Sample type, equipment and materials/reagents/supplies

1.5. Sample type
3.1.1. Urine

1.6. Equipment
3.1.2. Microscope
3.1.3. Bunsen burner
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 1.7. Materials/reagents/supplies
3.1.4. Urine Multi-strips
3.1.5. Frosted slides or plain clean slides
3.1.6. Cover slips
3.1.7. Centrifuge tubes
3.1.8. Tissue paper/ paper towels
3.1.9. Marker
3.1.10. Urine standard chart

4.0. Responsibility
1.8. The laboratory in-charge is responsible for the implementation of this
procedure
1.9. All technologists authorized to work in EQA laboratories are responsible
for the implementation of this procedure

5.0. Procedure
1.10. Ensure that the patient’s names on the request form corresponds with the
labeling on the patient’s sample. Use microbiology work sheets to report the sample
findings after analysis
1.11. Observe appearance of the urine macroscopically i.e. color and turbidity
and record on the worksheet
1.12. Pour about 5mls of the urine sample into a centrifuge tube and label the
tube with the patient lab number
1.13. Dip the urine strip into the urine in the centrifuge tube for about 10
seconds.
1.14. Remove the strip and blot off the excess urine from the strip onto tissue
paper
1.15. Compare the urine strip and standard chart on the urine container within
1 minute and record the biochemical reactions on the request form
1.16. Centrifuge the urine sample for 3 minutes at 3000rpm
1.17. Pour out the supernatant into the sink and suspend the deposit by
tapping the bottom of the centrifuge tube
1.18. Transfer a drop of the urine deposit on a clean glass slide and cover slip
1.19. Place the slide on the microscope stage and focus using x10
1.20. Examine the preparation using x40 for clear details
1.21. Results

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 1.21.1. White cells (pus cells), Red blood cells, yeast cells, spermatozoa and
epithelial cells should be counted and expressed as a number per High
power field (i.e. 2-4 pus cells/hpf)
1.21.2. Casts i.e. hyaline, granular, white and red cell casts may be observed
1.21.3. Crystals i.e. calcium oxalate, uric acid, amorphous phosphate to be
reported when observed
1.21.4. Parasites i.e. ova of Schistosoma haematobium, trophozoites of
Trichomonas vaginalis
5.13. Reporting
5.13.1. Report macroscopic appearance of urine i.e. color and turbidity
5.13.2. Report the biochemical results
5.13.3. Report the number of cells per high power field (/hpf)
5.13.4. Report any parasites, casts, crystals present in the deposit
5.13.5. The patient’s final report is reported on HMIS as per the procedure for
reporting and release of results
5.14. Specimen Retention and storage
5.14.1. If analysis is not done immediately, store the samples at 2-8°C and
perform the test within 24 hours of collection
5.15. Limitations/Sources of Error
5.15.1. Overstayed urine at room temperature may cause false biochemical results
e.g. Nitrites and may also cause an increase in the number of bacteria and
turbidity

2.0. Related Procedures/ documents

6.1. Reporting and release of results (EQA-LAB-SOP008)

7.0. References
7.1. Practical Laboratory Manual for Health Centers in Eastern Africa by Jane Cartel and
Orgena Lema

8.0. Appendix
N/A

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP33

Laboratory Department Version: 1

Section: Microbiology Stool Analysis Copy No:
Effective Date:
1.0. Purpose /Applicability
1.1. Purpose
To describe the steps for performing the direct saline and iodine method for stool
analysis to aid in diagnosis of intestinal infestation

1.2. Scope
This procedure applies to the Microbiology section at the Equity Afia Health
facilities’
Laboratories

1.3. Principle & Safety

1.3.1. Principle
A small portion of fresh stool is mixed with physiological saline for the
BC’s, pus cells, trophozoites, cysts, larvae, ova of pathogenic intestinal
protozoa and helminthes

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviations, definitions and terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia
2.1.2. QC – Quality Control
2.1.3. GCLP – Good clinical laboratory practice
2.1.4. HMIS- Health Management Information System
2.1.5. RBC – Red blood cells

2.2. Definitions and terms

N/A

3.0. Sample type, equipment and materials/reagents/supplies

5.1. Sample type
5.1.1. Stool

5.2. Equipment

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 5.2.1. Microscope

5.3. Materials/reagents/supplies
3.1.1. Clean glass slides
3.1.2. Applicator sticks
3.1.3. Cover slips
3.1.4. Pencil or marker.
3.1.5. Tissue paper/ paper towels
3.1.6. Physiological Saline
3.1.7. Iodine solution

4.0. Responsibility
5.4. The laboratory in-charge is responsible for the implementation of this
procedure
5.5. All technologists authorized to work in EQA laboratories are responsible
for the implementation of this procedure

6.0. Procedure
6.1. Ensure that the patient’s names on the request form corresponds with the
labeling on the patient’s sample. Use microbiology work sheets to report the sample
findings after analysis
6.2. Label two slides with the patient’s lab reference number using a pencil
or marker
6.3. Observe the stool colour, consistency, blood, mucus and visible parasites
and record on the request form
6.4. Select a small portion of the stool (especially the parts that have
mucous) with an applicator stick and emulsify with saline on the two slides.
6.5. Remove extra faecal debris and add one drop of iodine solution on one
of the two slides
6.6. Place the wooden applicator stick in the bucket labeled “soiled
materials”
6.7. Apply a coverslip on these mixtures
6.8. Place each slide on the microscope stage and focus with x10 objective
and examine the mixture with x40 objective to observe structures and details
6.9. Record observations made on the work sheet
6.10. Place the slide in the container labeled “slides” which contains disinfectant
6.11. Place the stool specimen in the red bucket on the Microbiology bench labeled
“Processed Samples”
6.12. Reporting
4.1.1. Report macroscopic observations of the stool i.e. colour, consistency and
adult worms
4.1.2. Report any cyst, ova, larvae, trophozoites detected in the stool
microscopically

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 4.1.3. Report quantitatively i.e. few, moderate, many numbers of pus cell, red
and yeast Cells and starch granules seen e.g. moderate pus cells seen
4.1.4. The patient’s final report is reported on HMIS as per the procedure for
reporting and release of results

6.13. Specimen Retention and storage

6.13.1. After analysis is done all samples are kept in a bucket labeled “processed
samples” on the Microbiology bench for 24 hours and then disposed
4.1.5. If not processed immediately, all stool samples should be stored in Fridge
No. 5 at 2-8˚C for up to 3 days and then disposed

6.14. Limitations/Sources of Error

4.1.6. This method does not rule out parasitic infestation completely. Further test
example serological, radiology, histological test can be employed to rule
out parasitic infestation if need be.

6.0. Related Procedures/ documents

6.1. Reporting and release of results (EQA-LAB-SOP008)

7.1. References
7.2. Practical Laboratory Manual for Health Centres in Eastern Africa by Jane Cartel
and Orgencs Lema
7.3. District laboratory practice for Tropical countries by Monica Cheeseborough

8.0. Appendix
N/A

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP33

Laboratory Department Version: 1

Section: Microbiology Salmonella antigen test Copy No:
Effective Date:
1.0. Purpose /Applicability
6.15. Purpose
To describe the steps for performing the Salmonella antigen test using the first sign
kit to aid in diagnosis of Salmonellosis/Typhoid fever

6.16. Scope
This procedure applies to the Microbiology section at the Equity Afia Health
facilities’
Laboratories

6.17. Principle & Safety

4.1.7. Principle
The test is a qualitative immunochromatographic assay which employs
Antibodies specific to S.typhi lipopolysaccharide to selectively
identify S.typhi. As specimen flows through the absorbent
pad and through the Abs/colloidal gold complex, any
S.typhi antigen present in the sample bonds to the
conjugate forming an Ag/Abs complex. The sample and dye
complex continue to migrate along the membrane to the test band region
where Salmonella specific LPS Abs is immobilized. In the presence of
S.typhi, The Abs capture the complex forming a visible pink/purple band.

4.1.8. Safety
4.1.8.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

5.0. Abbreviations, definitions and terms

6.18. Abbreviations
5.1.1. EQA – Equity Afia
5.1.2. QC – Quality Control
5.1.3. GCLP – Good clinical laboratory practice
5.1.4. HMIS- Health Management Information System
5.1.5. Abs - Antibodies
5.1.6. Ags - Antigens
5.1.7. LPS – Lipopolysaccharides
5.1.8. S.typhi – Salmonella typhi

6.19. Definitions and terms

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 N/A

7.0. Sample type, equipment and materials/reagents/supplies

7.1. Sample type
7.2. Stool
7.3. Blood

7.4. Equipment
7.5. Centrifuge

7.6. Materials/reagents/supplies
5.1.9. Test devices
5.1.10. Droppers
5.1.11. S.typhi Ag test
5.1.12. Stool sample buffer
5.1.13. Pipette 1000u/l.
5.1.14. Pipette tip

6.0. Responsibility
7.7. The laboratory in-charge is responsible for the implementation of this
procedure
7.8. All technologists authorized to work in EQA laboratories are responsible
for the implementation of this procedure

8.0. Procedure
8.1. Ensure that the patient’s names on the request form corresponds with the
labeling on the patient’s sample. Use microbiology work sheets to report the sample
findings after analysis
8.2. Bring all materials to room temperature
8.3. For stool samples, Pipette 500 u/l of extraction buffer into a clean tube
and add about 250 grams of stool. Shake thoroughly to mix and leave to stand on the
bench for 5 minutes
8.4. Use the provided pipette to transfer the sample from the supernatant of
the stool extract
8.5. Transfer 3 drops to the sample well (S) of the S. typhi test device
8.6. For blood Centrifuge the sample for 3 minutes at 3000rpm, use the
provided pipette to transfer 3 drops of serum/plasma to the sample well (S)
8.7. Read the result 20 minutes after placing the drops into the sample well
8.8. A strong positive sample may show reactive band earlier
8.9. Results
Result Observation
Positive A distinct pink colored band appears on the test line (T)
region in addition to a pink line on the control line region
(C)
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 Negative No line appears in the test line region (T). A distinct pink
line shows on the control line region (C)
Invalid The control line does not becomes visible with 20
minutes after addition of sample
8.10. Reporting
6.1.1. When Two lines appear in the T and C regions, report as S. typhi positive
6.1.2. When a line appears in the C region only, report as S. typhi negative
6.1.3. When no line/band appears in the control region, the test is invalid and
should be re-run using another strip
6.1.4. The patient’s final report is reported on HMIS as per the procedure for
reporting and release of results
8.11. Specimen Retention and storage
8.11.1. If analysis is not done immediately, store the sample at 2-8° C for up to
three days after collection
8.12. Limitations
8.12.1. The test is for qualitative detection of S. typhi in stool or plasma/serum
Sample.
8.12.2. It does not indicate the quantity of the antigens

9.0. Related Procedures/ documents

6.1. Reporting and release of results (EQA-LAB-SOP008)

10.0. References
10.1. Salmonella Ag kit manufacturer’s instructions / insert

8.0. Appendix
N/A

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP34

Laboratory Department Version: 1

Section: Microbiology Rota-Adeno virus test Copy No:
Effective Date:

1.0. Purpose /Applicability

1.1. Purpose
To describe the steps for performing one step Rota -Adeno virus test to aid in
detection of the two viruses.

1.2. Scope
This procedure applies to the Microbiology section at the Equity Afia Health
facilities’
Laboratories

1.3. Principle & Safety

1.3.1. Principle
One step Rota-Adeno comb test device is a qualitative immunoassay for
Detection of Rota/Adeno viruses in human faeces. The membrane of the
test device is pre-coated with anti Rota/Adeno antibody. The mixture of
stool and buffer migrates upward on the membrane chromatographically
by capillary action to react with anti Rota/Adeno virus antibody in the Test
(T) and control (C) regions to generate blue and red lines respectively

1.3.2. Safety
1.3.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviations, definitions and terms

2.1. Abbreviations
2.1.1. EQA – Equity Afia
2.1.2. QC – Quality Control
2.1.3. GCLP – Good clinical laboratory practice
2.1.4. HMIS- Health Management Information System
2.1.5. Abs - Antibodies
2.1.6. Ags - Antigens

2.2. Definitions and terms

2.2.1. Anti-Rota-Adeno Abs – These are antibodies that react against Rota-
Adeno antigen

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3.0. Sample type, equipment and materials/reagents/supplies
3.1. Sample type
3.1.1. Stool

3.2. Equipment
3.2.1. Centrifuge

3.3. Materials/reagents/supplies
3.3.1. Test devices
3.3.2. Droppers
3.3.3. Rota/Adeno buffer with sample applicator
3.3.4. Rota/Adeno test cassettes or strips

4.0. Responsibility
4.1. The laboratory in-charge is responsible for the implementation of this
procedure
4.2. All technologists authorized to work in EQA laboratories are responsible
for the implementation of this procedure

5.0. Procedure
5.1. Ensure that the patient’s names on the request form corresponds with the
labeling on the patient’s sample. Use microbiology work sheets to report the
sample findings after analysis
5.2. Bring all materials to room temperature
5.3. Unscrew the specimen container and at the same time unscrew the
Rota/Adeno buffer. Use the Rota/Adeno applicator to pick the stool sample
5.4. For solid samples, randomly stab the applicator into the fecal sample in
at least three different sites to collect approximately 50 mg
5.5. For liquid samples, hold the dropper vertically and aspirate fecal sample
and transfer two drops (approximately 50ul) into the dilution buffer
5.6. Screw on and tighten the cap onto the dilution buffer tube and shake
vigorously to mix. Leave the mixture to stand on the bench for two minutes for
extraction of the Ags to occur
5.7. Remove the test cassettes/devices from their pouch and use it
immediately
5.8. Hold the buffer tube upright and break off the tip. Invert the bottle and
transfer two drops of the extracted sample onto the test cassette’s sample well
5.9. Read the result within 10 minutes after dispensing the specimen
5.10. Results
Result Observation
Positive (Rota- Adeno A coloured band/line appears in the control region (C)
virus) and two coloured bands appear at A and R line regions
respectively
Positive Rota virus A coloured band appears in the Control region (C) and
another line appears in the Rota (R) region
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 Positive Adeno virus A coloured band appears in the Control region (C) and
another line appears in the Adeno (A) region
Negative One coloured band appears in the control area (c) only
Invalid Control line /band fails to appear
5.11. Reporting
5.11.1. When Three lines appear in the R, A and C regions, report as Rota-
Adeno positive
5.11.2. When a line appears in the R and C regions only, report as Rota virus
positive
5.11.3. When a line appears in the A and C regions only report as Adeno
positive
5.11.4. When a line appears in the control region only, report as Negative
5.11.5. When no line/band appears in the control region, the test is invalid and
should be re-run using another strip
5.11.6. The patient’s final report is reported on HMIS as per the procedure for
reporting and release of results

5.12. Specimen Retention and storage

5.12.1. If analysis is not done immediately, store the sample at room
temperature (18-28°C) on a dry surface and away from sunlight. The
test should be performed within 24 hours of sample collection

5.13. Limitations
5.13.1. The result should not be read after 20 minutes as it might give false
Positive results
5.13.2. One step Rota-Adeno combs devices only indicate presence of Rota-
Adeno virus in specimens but not severity of infection

6.0. Related Procedures/ documents

6.1. Reporting and release of results (EQA-LAB-SOP008)

7.0. References
7.1. Rota-Adeno virus kit manufacturer’s instructions / insert

8.0. Appendix
N/A

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EQA LOGO Technical Procedure SOP No: EQA-LAB-SOP34

Laboratory Department Version: 1

Section: Microbiology Helicobacter pylori test Copy No:
Effective Date:
1.1. Purpose/Applicability
1.2. Purpose
To describe the steps used in detecting H. pylori antigen in stool samples using
one step quantitative test to aid in diagnosis of H. Pylori infection.

1.3. Scope
This procedure applies to the Microbiology section at the Equity Afia Health
facilities’ Laboratories

1.4. Principle & Safety

1.4.1. Principle
One step H. pylori Ag is a quantitative immunoassay for the detection of
H. pylori Ag in stool. In the test, the membrane is pre-coated with H.
pylori antibodies on the test line region. Upon adding the specimen, if
antigens are present in the stool, they react with the antibodies in the strip.
The mixture migrates upward on the strip membrane by capillary action to
react with H. pylori antibodies and generate a coloured line.

1.4.2. Safety
1.4.2.1. Always wear personal protective equipment when handling
potentially infectious material and practice GCLP

2.0. Abbreviations, Definitions and Terms

2.1. Abbreviations
2.1.1. EQA- Equity Afia Health Facility
2.1.2. SOP- Standard Operating Procedure
2.1.3. Abs - Antibodies
2.1.4. Ags – Antigens
2.1.5. H.pylori – Helicobacter pylori
2.1.6. GCLP – Good Clinical Laboratory Practice

2.2. Definitions and terms

2.2.1. Anti H. pylori Abs – These are antibodies that react with H. pylori
antigen

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3.0. Sample type, Equipment and Materials/Reagents/Supplies
3.1. Sample type
3.1.1. Stool

3.2. Equipment
N/A

3.3. Materials/ Reagents/ Supplies

3.3.1. Test devices
3.3.2. Droppers
3.3.3. H. pylori buffer with sample applicator
3.3.4. H. pylori test cassettes

4.0. Responsibilities
4.1. The Laboratory in-charge is responsible for the implementation of this
procedure
4.2. All technologists authorized to work in EQA laboratories are responsible
for the implementation of this procedure

5.0. Procedure
5.1. Ensure that the patient’s names on the request form corresponds with the
labeling on the patient’s sample. Use microbiology work sheets to report the
sample findings after analysis
5.2. For solid samples, unscrew the specimen container and at the same time
unscrew the H. pylori buffer. Use the H. pylori buffer applicator to pick the
stool sample
5.3. For solid samples, randomly stab the applicator into the fecal sample in at
least three different sites to collect approximately 50 mg
5.4. For liquid samples, hold the dropper vertically and aspirate fecal sample and
transfer two drops into the dilution buffer.
5.5. Screw on and tighten the cap onto the dilution buffer tube and shake
vigorously to mix. Leave the mixture to stand on the bench for 2 minutes for
extraction of the Ags to occur
5.6. Remove the test cassettes from their pouch and use it immediately
5.7. Hold the buffer tube upright and break off the tip. Invert the bottle and
transfer two drops of the extracted sample onto the test cassette’s sample
region
5.8. Read the result within 10 minutes after dispensing the specimen

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 5.9. Results
Result Observation
Positive Two distinct pink-red bands appear; one in the test and one
in the control region
Negative One band appears in the control area (c)
Invalid No line appears in the control region (c)

5.10. Reporting
5.10.1. When two pink-red lines appear, report as H. pylori positive
5.10.2. When a pink-red line appears in the control region only, report as
Negative
5.10.3. When no line/band appears in the control region, the test is invalid
and should be re-run using another strip
5.10.4. The patient’s final report is reported on HMIS as per the procedure
for reporting and release of results

5.11. Specimen Retention and storage

5.12. If analysis is not done immediately, store the sample at room
temperature (18-25°C) on a dry surface and away from sunlight. The test
should be performed within 24 hours of sample collection

5.13. Limitations
5.13.1. The result SHOULD NOT be read after 20 minutes as it might give
false positive results

6.0. Related Procedures/ documents

6.1. Laboratory Users’ Handbook
6.2. Reporting and release of results

7.1. References
7.2. H. pylori kit manufacturer’s instructions / insert

8.0. Appendix
N/A

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 POST ANALYTICAL

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