quality system for blood establishments morris r. dixon mm,mt(ascp)ssb director of operations blood...

Quality System for Blood Establishments

Morris R. Dixon MM,MT(ASCP)SSB

Director of Operations

Blood Systems Laboratories

Dallas, Texas, USA

Blood Systems Laboratories

Blood Systems LaboratoriesBSL Customers

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• Two Laboratories Dallas, TX Phoenix, AZ

• Testing 3 million samples per year• Inspected by: US FDA AABB EMEA (EU) Austria Ireland Germany UK (Directive 2005/62/EC

Regulations Commission Directive 2005/62/EC

Quality Policies

Standard Operating Procedures

Documentation Evidence of Compliance

A quality system for blood establishments should embrace the principles of quality management, quality assurance, continuous quality improvement, and should include:

PersonnelPremises and EquipmentDocumentationCollectionTesting and ProcessingStorage and DistributionContract ManagementNon-Conformance and Self-InspectionQuality ControlBlood Component RecallExternal and Internal Auditing

Blood and blood components imported from third countries….. should meet equivalent Community standards and specifications relating to a quality system for blood establishments as set out in this Directive.

Directive 2005/62/EC

Annex

Quality System Standards and Specifications

1.1.1 Quality System

Quality shall be recognised as being the responsibility of all persons involved in the processes of the blood establishment with management ensuring a systematic ap-proach towards quality and the Implemen- tation and maintenance of a quality system.

The achievement of

Quality System Standards is

everyone’s job

Director→Staff

1.1.3 Quality System The quality system shall ensure that all critical

processes are specified in appropriate instruc- tions and are carried out in accordance with the standards and specifications set out in this Annex.

Management shall review the system at regular intervals to verify its effectiveness and introduce corrective measures if deemed

necessary.

Why Standard Operating Procedures?

• Define policies.

• Describe procedures.

• Control processes.

• Meet regulatory requirements.

USFDA CFR Part 211.100(a)

There shall be written procedures for pro-

duction and process controls to assure that products have the strength, purity identity and quality they are represented

to possess.

USFDA CFR Part 606.100 (b)

Written SOPs shall be maintained for all

steps to be followed in the collection, pro-

cessing, testing, storage and distribution of blood and blood components.

Procedures shall be available for use in the areas where the procedures are performed.

1.2.1 Quality Assurance All blood establishments and hospital

blood banks shall be supported by a quality assurance function, whether internal or related, in fulfilling quality assurance. That function shall be invol-

ved in all quality-related matters and review and approve all appropriate quality

related documents.

USFDA CFR Part 211.22 (a)

There shall be a quality control unit that shall have the responsibility and authority to approve or reject all components…and the authority to review production records to assure that no errors have occurred or, if errors have occurred, that they have been fully investigated.

USFDA CFR Part 211.22 (c)

The quality control unit shall have the responsibility for approving or rejecting all procedures or specifications impacting on the identity, strength, quality, and purity of the drug product.

1.2.2 Quality Assurance

All procedures, premises, and equipment that have an influence on the quality and safety of blood and blood components shall be validated prior to introduction and be re-validated at regular intervals deter- mined as a result of these activities.

2.1 Personnel and Organisation

Personnel in blood establishments shall be available in sufficient numbers to carry out the activities related to the collection, testing, processing, storage and distrib-

ution of blood and blood components and be trained and assessed to be competent to perform their tasks.

3.1 Premises (General) Premises including mobile sites shall be

adapted and maintained to suit the activities to be carried out. They shall enable the work to proceed in a logical sequence so as to minimise the risk of errors, and shall allow for effective cleaning and maintenance in order to minimise the risk of contamination.

4.1 Equipment and Materials

All equipment shall be validated, calibrated and maintained to suit its intended purpose. Operating instructions shall be available and appropriate records kept.

4.3 Equipment and Materials

Only reagents and materials from approved suppliers that meet the docu- mented requirements and specifications shall be used. Critical materials shall be released by a person qualified to perform this task.

5.1 Documentation

Documents setting out specifications, procedures and records covering each activity performed by the blood estab-

lishment shall be in place and kept up to date.

5.3 Documentation

All significant changes to documents shall be acted upon promptly and shall be reviewed, dated and signed by a person authorised to perform this task.

Effective Documentation

Trackability – The steps of the process.

Traceability – What happened at each

step.

Concurrent Documentation

Is documentation of an action prior to

performing another action.

USFDA CFR 606.160 (a)(1) Records

Records shall be maintained concurrently with the performance of each significant step in the collection, processing, com-

patibility testing, storage and distribution of each unit of blood and blood components so that all steps can be clearly traced.

All records shall be legible and indelible, and shall identify the person performing the work.

6.1.2 Donor Eligibility

The donor interview shall be conducted in such a way as to ensure confidentiality.

6.2.1 Collection of Blood and Blood Components

The blood collection procedure shall be designed to ensure that the identity of the donor is verified and securely recorded and that the link between the donor and the blood, blood components and blood samples is clearly established.

6.3.1 Laboratory Testing

All laboratory testing procedures shall be validated before use.

6.3.3 Laboratory Testing

There shall be clearly defined procedures to resolve discrepant results and ensure that blood and blood components that have a repeatedly reactive result in a serological screening test for infection with the viruses mentioned in Annex IV to Directive 2002/98/EC shall be excluded from therapeutic use and be stored separately in a dedicated environment.

6.3.3 Laboratory Testing (Continued)

Appropriate confirmatory testing shall take place. In case of confirmed positive results, appropriate donor management shall take place including the provision of information to the donor and follow-up procedures.

6.3.4 Laboratory Testing

There shall be data confirming the suit- ability of any laboratory reagents used in the testing of donor samples and blood component samples.

6.3.5 Laboratory Testing

The quality of the laboratory testing shall be regularly assessed by the participation on a formal system of proficiency testing, such as an external quality assurance programme.

6.6.1 Release of Blood and Blood Components

There shall be a safe and secure system to prevent each single blood and blood component from being released until all mandatory requirements set out in this directive have been fulfilled.

Each blood establishment shall be able to demonstrate that each blood or blood

component has been formally released by an authorised person.

6.6.1 Release of Blood and Blood Components (Continued)

Records shall demonstrate that before a blood component is released, all current declaration forms, relevant medical re- cords and test results meet all acceptance criteria.

7.2 Storage and Distribution

Procedures for storage and distribution shall be validated to ensure blood and blood component quality during the entire storage period and to exclude mix-ups of blood components.

All transportation and storage actions, including receipt and distribution, shall be defined by written procedures and specifications.

9.2 Complaints

All complaints and other information, including serious adverse reactions and serious adverse events, which may sug- gest that defective blood components have been issued, shall be documented, carefully investigated for causative factors of the defect and, where necessary, fol- lowed by recall and the implementation of corrective actions to prevent recurrence.

9.2 Complaints (Continued)

Procedures shall be in place to ensure that the competent authorities are notified as appropriate of serious adverse reactions or serious adverse events in accordance with regulatory requirements.

9.4.1 Corrective and Preventive Actions

A system to ensure corrective and preventive actions on blood component non-conformity and quality problems shall be in place.

9.4.2 Corrective and Preventive Actions

Data shall be routinely analysed to identify quality problems that may require cor- rective action or to identify unfavorable trends that may require preventive action.

9.4.3 Corrective and Preventive Action

All errors and accidents shall be docu- mented and investigated in order to identify system problems for correction.

Deviation Management

Is the tracking of a deviation from established SOPs.

Deviation Management System

• Detect deviations.

• Report deviations.

• Analyze deviations.

• Correct deviations.

• Prevent deviations.

USFDA CFRs

• 211.180(e) and (f), General Requirements

• 211.192, Production Record Review

• 211.198, Complaint Files

• 600.12, Records

• 606.170, Adverse Reaction File

10.1 Self-Inspection, Audits and Improvements

Self-inspection or audit systems shall be in place for all parts of the operations to verify compliance with the standards set out in this Annex. They shall be carried out regularly by trained and competent persons in an independent way according to approved procedures.

10.2 Self-inspection, Audits and Improvements

All results shall be documented and appropriate corrective and preventive actions shall be taken in a timely and effective manner.

Red Cell Serology - Bedford 2009 DeviationsYTD: CR’s = 13 Avg=3.3 NR’s = 6 Avg= 1.52008: CR’s =29 Avg=2.4 NR’s = 9 Avg= 0.8

60

3 3 3 1 2 3 1 3 15

1

6

15

1419

17

1 2 12

1

31

2

1

11

2

1

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

CR CC NR RRC

Viral Marker Testing - Bedford 2009 DeviationsYTD: CR’s = 7 Avg= 1.75 NR’s = 2 Avg= 0.52008: CR’s =53 Avg= 4.4 NR’s = 10 Avg= 0.8

61

4

6

3

1 1

3 32 2

3

1 1

65

8 81

1 1

1

1 11 1

1

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

CR CC NR RRC

Bedford Total Deviations NormalizedPer 100,000 Samples

62

0.00

0.20

0.40

0.60

0.80

1.00

2007 0.40 0.59 0.58 0.47 0.71 0.48 0.78 0.89 0.80 0.80 0.61 0.49

2008 0.48 0.32 0.23 0.28 0.30 0.24 0.26 0.20 0.21 0.32 0.14 0.33

2009 0.19 0.19 0.16

J an F eb Mar Apr May J un J ul Aug S ep Oct Nov Dec

Process Failure/SOP DeviationNormalized Per 100,000 Samples

63

Process Failure/SOP Deviation Normalized/100,000

0.02.04.06.08.0

10.012.014.0

Tempe

Bedford

Questions?