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iso 15189

1.    A continuing education program shall be provided for personnel participating in managerial and technical processes

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iso 15189

2.    A description of the complaint handling process shall be made available to users

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iso 15189

3.    A list of all referral laboratories and consultants shall be kept up to date

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4.    A member of management shall be appointed as the management representative

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5.    A person with appropriate training and experience shall be appointed to manage the training and competence assessment of personnel performing POCT

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6.    A record regarding confidentiality shall be maintained

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7.    A record regarding facilities shall be maintained

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8.    A record regarding impartiality shall be maintained

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9.    A record regarding the legal entity shall be maintained

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iso 15189

10. Adverse events and accidents directly attributable to specific equipment shall be investigated and reported to the manufacturer or supplier, and to the appropriate authorities if necessary

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iso 15189

11. Adverse events and accidents directly attributable to specific reagents or consumables shall be investigated and reported to the manufacturer or supplier and to the appropriate authorities if necessary

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iso 15189

12. All documents associated with the analytical process shall be subject to document control

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iso 15189

13. All information associated with issued reports shall be retained in accordance with management system requirements

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iso 15189

14. All personnel involved in laboratory activities shall have access to the management system documentation

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15. Authorized personnel shall regularly evaluate the examination methods implemented by the laboratory to ensure they are clinically appropriate for the requests received

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16. Biological reference intervals and clinical decision limits shall be reviewed regularly

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17. Biological reference intervals and clinical decision limits, when necessary for the interpretation of examination results, shall be defined and communicated to users

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18. Calculations and data transfers shall be checked systematically and appropriately

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19. Conclusions and actions resulting from management reviews shall be communicated to laboratory personnel

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20. Consumables that may affect the quality of examinations shall be verified for performance before use

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iso 15189

21. Corrective actions shall be appropriate to the consequences of the nonconformities encountered

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22. Each request for examination(s) accepted by the laboratory shall be considered a contract

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23. Equipment shall be used by trained, authorized, and competent personnel

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24. Evaluations of IVDs shall be regularly reviewed

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25. Every report shall include the following information - unless the laboratory has valid, documented reasons for omitting it - on every page of the report: unique patient identification, the date of primary sample collection, and the report issue date

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iso 15189

26. Externally originated documents shall be approved

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iso 15189

27. Facilities and environmental conditions shall be suitable for laboratory activities

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iso 15189

28. Facilities intended for sample collection shall allow for sample collection in a manner that does not invalidate the results

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iso 15189

29. Facilities intended for sample collection shall have separate patient reception and sample collection areas

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30. For genetic examinations, traceability to reference genetic sequences shall be established

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31. Instructions for use for reagents and consumables, including those provided by manufacturers, shall be readily accessible

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32. Laboratory activities shall be carried out impartially

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33. Laboratory activities shall be performed in a manner that meets the requirements of ISO 15189

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34. Laboratory management shall ensure that actions taken following a management review are carried out within a specified timeframe

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35. Laboratory management shall ensure that appropriate advisory services and interpretations are made available and meet the needs of patients and users

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36. Laboratory management shall ensure that the integrity of the management system is preserved when changes to the management system are planned and implemented

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37. Laboratory management shall establish and maintain objectives and policies to meet the needs and requirements of its patients and users

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38. Laboratory management shall establish, document, and maintain objectives and policies

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39. Laboratory management shall establish, implement, and maintain processes to identify risks of harm to patients

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40. Laboratory management shall establish, implement, and maintain processes to identify opportunities for improving patient care associated with its examinations and activities

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41. Laboratory management shall provide evidence of its commitment to the development and implementation of the management system and to the continual improvement of its effectiveness

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42. Laboratory management shall review its management system at planned intervals

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43. Laboratory procedures shall include acceptable timeframes for adding examinations to the same sample

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iso 15189

44. Laboratory users shall be informed of any changes to a contract that may impact examination results

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iso 15189

45. Management review inputs shall be recorded

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46. Management review outputs shall be a record of decisions and actions relating at least to the effectiveness of the management system and its processes

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47. Measurement uncertainty (MU) should be taken into account when verifying or validating a method, where relevant

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48. Objectives and policies shall address the competence, quality, and consistency of laboratory activities

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iso 15189

49. Personnel shall have access to toilets, a source of drinking water, and facilities for storing personal protective equipment

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50. Procedures for issuing revised or modified results shall ensure that the reason for the modification is recorded and noted in the revised report, where relevant

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51. Process mapping shall be established and documented

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52. Provisions for controlling facilities shall be implemented, recorded, monitored, and periodically reviewed

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53. Records shall be created for each activity affecting the quality of an examination at the time it is performed

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54. Records shall be maintained for each item of equipment that influences the results of laboratory activities

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55. Records shall be maintained for each reagent and consumable contributing to the performance level of examinations

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56. Records of feedback and actions taken shall be retained

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iso 15189

57. Requirements for facilities and environmental conditions necessary for laboratory activities shall be specified, monitored, and recorded

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58. Responsibility for laboratory information systems rests ultimately with the laboratory

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59. Results shall be reviewed and approved before release

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60. Staff shall have access to toilets, a source of drinking water, and facilities for storing personal protective equipment and clothing

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61. Storage space and conditions shall be suitable to ensure the continued integrity of samples, equipment, reagents, consumables, documents, and records

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62. Taking into account analyte stability in the primary sample, the time interval between sample collection and analysis performance shall be specified and monitored where relevant

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63. The duties and responsibilities of the laboratory director shall be documented

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64. The examination and handling of complaints shall not result in discriminatory actions

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65. The following records relating to validation performed shall be retained: specific requirements regarding intended use

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66. The following records relating to verification performed shall be retained: results obtained

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67. The laboratory shall appoint a person with appropriate training and experience as the POCT quality manager

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68. The laboratory shall authorize personnel to perform specific laboratory activities, including the following: review of results, and the issuing and release of reports

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69. The laboratory shall be an entity that can be held legally responsible for its activities

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70. The laboratory shall communicate its requirements to subcontracting laboratories and consultants providing interpretations and advisory services regarding the procedures, analyses, reports, and advisory services to be delivered

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71. The laboratory shall communicate to laboratory personnel the importance of meeting user needs and requirements

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72. The laboratory shall conduct evaluations at planned intervals

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73. The laboratory shall conduct internal audits at planned intervals

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74. The laboratory shall continually improve the effectiveness of the management system

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75. The laboratory shall define quality indicators to evaluate performance across all key aspects of the processes

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iso 15189

76. The laboratory shall document its analytical procedures in sufficient detail to ensure consistent application of its activities and the validity of its results

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iso 15189

77. The laboratory shall ensure that alterations to records can be traced to previous versions or to original observations

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78. The laboratory shall ensure that authorities and responsibilities regarding the management of information systems are specified

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iso 15189

79. The laboratory shall ensure that changes and the current revision status of documents are identified

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80. The laboratory shall ensure that documents are uniquely identified

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81. The laboratory shall ensure that persons performing work under the control of the laboratory are made aware of relevant objectives and policies

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82. The laboratory shall ensure that products and services provided by external providers that impact laboratory activities are appropriate when such products and services are intended to be incorporated into the laboratory’s own activities

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83. The laboratory shall ensure that risks associated with emergency situations or other conditions in which laboratory activities are limited or unavailable have been identified

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iso 15189

84. The laboratory shall ensure the extent of the verification of examination method is sufficient to ensure the validity of results pertinent to clinical decision-making

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iso 15189

85. The laboratory shall establish a management system for reagent and consumable stocks

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iso 15189

86. The laboratory shall establish a procedure for registration, participation, and performance of external quality assessment (EQA) for the analytical methods used

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87/165

iso 15189

87. The laboratory shall establish and maintain metrological traceability of its measurement results through an unbroken and documented chain of calibrations

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88/165

iso 15189

88. The laboratory shall establish and periodically evaluate the suitability of sample transport systems

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89/165

iso 15189

89. The laboratory shall establish and retain legible records

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90/165

iso 15189

90. The laboratory shall establish, document, implement, and maintain a management system

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91/165

iso 15189

91. The laboratory shall evaluate the effectiveness of the actions taken

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92/165

iso 15189

92. The laboratory shall have a procedure for establishing and regularly reviewing contracts regarding its laboratory services

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93/165

iso 15189

93. The laboratory shall have a procedure for managing oral requests for examinations, where applicable, which includes the transmission of a written confirmation of the request to the laboratory within a specified timeframe

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94/165

iso 15189

94. The laboratory shall have a procedure for monitoring the validity of results

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95/165

iso 15189

95. The laboratory shall have a procedure to verify its ability to correctly implement examination methods before using them for the first time

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96/165

iso 15189

96. The laboratory shall have a process for handling complaints

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97/165

iso 15189

97. The laboratory shall have a process for handling situations where any aspect of its laboratory activities or examination results does not conform to its own procedures, quality specifications, or user requirements

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98/165

iso 15189

98. The laboratory shall have a process for managing personnel competence

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99/165

iso 15189

99. The laboratory shall have a sample receipt procedure that includes criteria for sample acceptance and rejection

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100/165

iso 15189

100.             The laboratory shall have access to a sufficient number of competent personnel to carry out its activities

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101/165

iso 15189

101.             The laboratory shall have access to the data and information necessary to perform laboratory activities

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102/165

iso 15189

102.             The laboratory shall have access to the equipment necessary for the correct performance of laboratory activities

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103/165

iso 15189

103.             The laboratory shall have an escalation procedure that laboratory personnel can follow if they are unable to contact the person in charge

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104/165

iso 15189

104.             The laboratory shall have an induction program for new personnel

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105/165

iso 15189

105.             The laboratory shall have an internal quality control (IQC) procedure to continuously monitor the validity of examination results, in accordance with specified criteria

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106/165

iso 15189

106.             The laboratory shall have available the personnel, facilities, equipment, reagents, consumables, and support services necessary for the management and performance of its activities

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107/165

iso 15189

107.             The laboratory shall have documented information demonstrating the competence of its personnel

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108/165

iso 15189

108.             The laboratory shall have personnel who possess the authority and resources necessary to carry out their duties

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109/165

iso 15189

109.             The laboratory shall have planned processes to maintain operations in the event of a failure or during an outage of information systems affecting laboratory activities

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110/165

iso 15189

110.             The laboratory shall have preventive maintenance programs established based on manufacturer instructions

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111/165

iso 15189

111.             The laboratory shall have procedures and maintain records concerning the definition, review, and approval of laboratory requirements regarding all products and services provided by external providers

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112/165

iso 15189

112.             The laboratory shall have procedures and maintain records concerning the transmission of samples to referral laboratories

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113/165

iso 15189

113.             The laboratory shall have procedures and maintain records records concerning the definition of competence requirements

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114/165

iso 15189

114.             The laboratory shall have procedures for each pre-analytical activity and make them available to the relevant personnel

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115/165

iso 15189

115.             The laboratory shall have procedures for the calibration of equipment that has a direct or indirect impact on examination results

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116/165

iso 15189

116.             The laboratory shall have procedures for the collection and handling of primary samples

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117/165

iso 15189

117.             The laboratory shall have processes for the selection, acquisition, installation, acceptance testing, handling, transport, storage, use, maintenance, and decommissioning of equipment

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118/165

iso 15189

118.             The laboratory shall have processes for the selection, procurement, receipt, storage, acceptance testing, and inventory management of reagents and consumables

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119/165

iso 15189

119.             The laboratory shall have processes to ensure optimal patient care when a sample is nonconforming due to incorrect patient or sample identification

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120/165

iso 15189

120.             The laboratory shall identify and select opportunities for improvement

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121/165

iso 15189

121.             The laboratory shall identify risks and opportunities for improvement associated with laboratory activities

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122/165

iso 15189

122.             The laboratory shall identify risks related to patient care within pre-analytical, analytical, and post-analytical processes

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123/165

iso 15189

123.             The laboratory shall implement corrective action proportional to the likelihood of the nonconformity recurring

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124/165

iso 15189

124.             The laboratory shall implement necessary procedures regarding the identification, storage, protection against unauthorized access or modification, backup, archiving, retrieval, retention time, and destruction of its records

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125/165

iso 15189

125.             The laboratory shall implement planned action to respond to emergency situations

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126/165

iso 15189

126.             The laboratory shall inform users of any clinically significant differences in result comparability

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127/165

iso 15189

127.             The laboratory shall maintain equipment and replace it if necessary to ensure the quality of examination results

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128/165

iso 15189

128.             The laboratory shall maintain the confidentiality of patient information

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129/165

iso 15189

129.             The laboratory shall make appropriate information available to its users and patients

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130/165

iso 15189

130.             The laboratory shall monitor its performance regarding examination methods, by comparison with the results of other laboratories

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131/165

iso 15189

131.             The laboratory shall obtain the patient’s informed consent for all procedures performed on them

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132/165

iso 15189

132.             The laboratory shall plan, establish, implement, and maintain an internal audit program

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133/165

iso 15189

133.             The laboratory shall prevent the reporting of patient results if internal quality control (IQC) does not meet defined acceptance criteria

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134/165

iso 15189

134.             The laboratory shall prioritize and control identified risks

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135/165

iso 15189

135.             The laboratory shall provide information and instructions regarding pre-collection activities that are sufficiently detailed to ensure sample integrity

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136/165

iso 15189

136.             The laboratory shall record decisions made and actions implemented regarding risks and opportunities for improvement

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137/165

iso 15189

137.             The laboratory shall record the comparability results obtained and their acceptability

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138/165

iso 15189

138.             The laboratory shall retain records as evidence of the nature of nonconformities

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139/165

iso 15189

139.             The laboratory shall seek feedback from its patients, users, and personnel

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140/165

iso 15189

140.             The laboratory shall select an internal quality control (IQC) material suitable for its intended use

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141/165

iso 15189

141.             The laboratory shall select and use examination methods that have been validated for their intended use so as to ensure the clinical utility of examination results

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142/165

iso 15189

142.             The laboratory shall specify and document the scope of laboratory activities

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143/165

iso 15189

143.             The laboratory shall specify competence requirements for each function influencing the results of laboratory activities

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144/165

iso 15189

144.             The laboratory shall specify its calibration and traceability requirements, which shall be sufficient to ensure consistent reporting of examination results

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145/165

iso 15189

145.             The laboratory shall specify the duration and conditions for sample retention after analysis

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146/165

iso 15189

146.             The laboratory shall specify the responsibility and authority of personnel

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147/165

iso 15189

147.             The laboratory shall store reagents and consumables in accordance with the manufacturer’s specifications

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148/165

iso 15189

148.             The laboratory shall validate examination methods in the following cases: methods designed or developed by the laboratory

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149/165

iso 15189

149.             The laboratory shall verify that equipment complies with specified acceptance criteria before being put into service or returned to service

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150/165

iso 15189

150.             The laboratory receiving the complaint shall be responsible for gathering all information necessary to evaluate the validity of the complaint

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151/165

iso 15189

151.             The organization’s management shall bear ultimate responsibility for establishing appropriate processes to monitor the accuracy and quality of examinations performed within the organization

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152/165

iso 15189

152.             The process for monitoring quality indicators shall be planned

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153/165

iso 15189

153.             The quality manual shall be established and maintained

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154/165

iso 15189

154.             The report shall include ...all information necessary for the interpretation of results

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155/165

iso 15189

155.             The report release date, if not included in the report itself, shall be readily retrievable if needed

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156/165

iso 15189

156.             The request for examination(s) shall be sufficiently detailed to ensure unequivocal patient traceability regarding the request and the sample

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157/165

iso 15189

157.             The retention period for records shall be specified

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158/165

iso 15189

158.             To ensure that sample collection and storage prior to analysis are performed safely, correctly, and in a clinically appropriate manner, the laboratory shall provide instructions regarding the verification of the identity of the patient from whom the primary sample was collected

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159/165

iso 15189

159.             To ensure the safe and timely transport of samples, the laboratory shall provide instructions for packaging samples for transport

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160/165

iso 15189

160.             When a nonconformity occurs, the laboratory shall determine the cause of the nonconformity

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161/165

iso 15189

161.             When a nonconformity occurs, the laboratory shall implement all necessary actions

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162/165

iso 15189

162.             When a nonconformity occurs, the laboratory shall respond to the nonconformity

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163/165

iso 15189

163.             When results are transmitted as a preliminary report, the final report shall always be communicated to the user

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164/165

iso 15189

164.             When revisions cannot be entered into the report generation system, a record of these revisions shall be maintained

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165/165

iso 15189

165.             When the laboratory uses an automated system for the selection, review, release, and reporting of results, it shall establish a procedure to ensure that the criteria for automated selection, review, and release are specified, approved, readily available for consultation, and understandable

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iso 15189

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