MODULE C: VERSLAG VAN DE hoofdAUDITOR (EN ISO 15189:2022)
MODULE C: VERSLAG VAN DE hoofdAUDITOR
(EN ISO 15189:2022)
1Vertegenwoordigers van de instelling
Functie Aan te passen naar de door de instelling gebruikte naamgeving |
Naam |
Verantwoordelijke managementsysteem |
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Technisch verantwoordelijke |
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… |
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2evaluatie van de opvolging van de corrigerende maatregelen naar aanleiding van de vorige audit
ID code van de voorgaande audit |
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De
evaluatie van de opvolging van de tekortkoming wordt genoteerd als
“+” wanneer alle elementen voldoende opgevolgd en opgelost zijn
en deze afgesloten kan worden.
Een nieuwe tekortkoming XX-Ay
of XX-By (XX= initialen auditor, y=volgnummer van de tekortkoming in
dit deelverslag), wordt gedefinieerd indien
er deelelementen nog niet opgelost zijn; en/of
er elementen niet in orde zijn; en/of
de doorgevoerde oplossing aanleiding gegeven heeft tot een nieuwe tekortkoming.
Tekortkoming vorige audit |
Beoordeling van de opvolging en effectiviteit van de genomen corrigerende maatregel(en) |
Evaluatie |
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3Verslag van de audit
Gelieve achter elk normelement de evaluatie aan te geven:
+ (bekeken en in orde);
XX-Ay of XX-By (bekeken, maar met tekortkoming: XX=initialen auditor, y=volgnummer van de tekortkoming in dit deelverslag);
nb (niet bekeken);
nvt (niet van toepassing).
Normeisen
EN ISO 15189: 2022 § 4: General requirements
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
4.1 |
4.1.1.3 |
Impartiality |
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4.1 |
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Impartiality: Structured and managed – committed – responsible & no compromise - identify threats - mitigate threats |
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4.2 |
4.1.1.3 - 5.10.1 – 5.4.2 |
Confidentiality |
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4.2.1 |
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Management of information: Responsible – legally enforceable agreements – management of all patient information – privacy & confidentiality – inform user and/or patient in advance |
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4.2.2 |
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Release of information: Release confidential information – notification of patient – information from a source other than the patient – confidential identity |
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4.2.3 |
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Personnel responsibility: Personnel acting on behalf of lab – keep confidential |
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4.3 |
4.1.1.3 - 4.1.2.2 – 4.4.1 – 4.14.2 - 5.4.2 - 5.4.3 – 5.4.6 – 5.4.7 -5.7.2 – 5.9.1 |
Requirements regarding patients |
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4.3 |
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Requirements regarding patients: Opportunities for patients – publicly available info – periodic review – disclosure of incidents – treatment with due care and respect – informed consent – closure, acquisition or merger – making relevant info available – free from discrimination |
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Belangrijkste bekeken documenten:
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EN ISO 15189: 2022 § 5: Structural and governance requirements
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
5.1 |
4.1.1.2 |
Legal entity |
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5.1 |
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Legal entity: Laboratory or organization – entity – legally responsible |
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5.2 |
4.1.1.4 |
Laboratory director |
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5.2.1 |
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Laboratory director competence: Person or persons – specified qualification, competence, delegated authority, responsibility, and resources |
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5.2.2 |
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Laboratory director responsibilities: Implementation – risk management – systematically identified and addressed – documented duties and responsibilities |
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5.2.3 |
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Delegation of duties: Selected duties or responsibilities – to qualified and competent personnel – documented – ultimate responsibility |
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5.3 |
4.1.1.1 – 4.1.2.2 - 4.1.2.3 - 4.2.2.2 – 4.7 |
Laboratory activities |
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5.3.1 |
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General: Specify and document the range – activities – sites – claim conformity – excludes externally provided laboratory activities on an ongoing basis |
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5.3.2 |
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Conformance with requirements: Meet requirements – this document – users – regulatory authorities – recognition – complete range |
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5.3.3 |
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Advisory activities: Appropriate laboratory advice and interpretation - communicating with laboratory users - choice and use of examinations - professional judgments - effective utilization – advising |
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5.4 |
4.1.2.5 –4.1.2.6 - 4.1.2.7 – 4.2.2.1 - 4.2.2.2 |
Structure and authority |
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5.4.1 |
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General: Define – parent organization – relationships - responsibility -authority - lines of communication and interrelationship – all personnel – procedures – consistent application - validity |
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5.4.2 |
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Quality management: Personnel - authority and resources – duties – MS – deviations – actions – reporting - effectiveness |
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5.5 |
4.1.2.2 - 4.1.2.3 – 4.1.2.4 – 4.14.7 |
Objectives and policies |
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5.5 |
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Objectives and policies: Needs and requirements – good professional practice – examinations – intended use – conform – measurable objectives - consistent with policies – integrity – changes – quality indicators – monitor performance |
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5.6 |
4.2.1 – 4.11 - 4.16.6 |
Risk management |
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5.6 |
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Risk management: Processes for identifying risks – develop actions – evaluated – effectiveness - modified |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
EN ISO 15189: 2022 § 6: Resource requirements
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
6.1 |
4.1.1.4 - 4.1.2.1 |
General |
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6.1 |
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General: Available – personnel – facilities – equipment – reagents – consumables – support services – manage and perform activities |
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6.2 |
4.1.1.3 - 4.1.1.4 - 4.1.2.1 - 4.1.2.7 - 5.1.1 - 5.1.2 - 5.1.3 - 5.1.4 - 5.1.5 - 5.1.6 -5.1.8 - 5.1.9 |
Personnel |
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6.2.1 |
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General: Sufficient number – competent personnel - impartially – ethical – accordance management system - communication - introduction programme |
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6.2.2 |
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Competence requirements: Specify competence requirements each function – ensure and manage competency – documented information |
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6.2.3 |
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Authorization: Authorization personnel |
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6.2.4 |
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Continuing education and professional development: Programme – all personnel – suitability – periodically reviewed |
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6.2.5 |
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Personnel records: Procedures – retain records – competence requirements – position descriptions - (re)training – authorization – monitoring |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
6.3 |
5.2.1 – 5.2.2 – 5.2.3 – 5.2.4 – 5.2.5 – 5.2.6 |
Facilities and environmental conditions |
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6.3.1 |
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General: Suitable – pre-examination sites – other sites – POCT Specify – monitor – record |
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6.3.2 |
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Facility controls: Implementation – records – monitoring – periodically reviewed - control of access – prevention (cross)contamination – safety – maintenance |
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6.3.3 |
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Storage facilities: Storage space – prevention cross contamination and deterioration – hazardous materials |
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6.3.4 |
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Personnel facilities: Toilet – drinking water – storage – space personnel activities |
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6.3.5 |
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Sample collection facilities: Enable collection – privacy, comfort patients – separate space reception and collection - first aid |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
6.4 |
5.3.1.1 – 5.3.1.2 – 5.3.1.3 – 5.3.1.4 – 5.3.1.5 – 5.3.1.6 – 5.3.1.7 |
Equipment |
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6.4.1 |
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General: Processes – proper functioning – prevent contamination or deterioration |
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6.4.2 |
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Equipment requirements: access – outside permanent control – requirements met – uniquely labelled/identified – register – maintain and replace equipment – ensure quality of results |
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6.4.3 |
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Equipment acceptance procedure: Verify – specified acceptability criteria – achieving measurement accuracy/uncertainty |
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6.4.4 |
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Equipment instructions for use: Safeguards – prevent unintended adjustments – trained/authorized/competent personnel – instructions available – used as specified |
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6.4.5 |
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Equipment maintenance and repair: Preventive maintenance programmes – records – (safe) working condition – out of service – decontaminate – space for repairs - personal protective equipment |
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6.4.6 |
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Equipment adverse incident reporting: Investigated – reported – procedure – manufacturer recall |
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6.4.7 |
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Equipment records: Records – available – lifespan equipment |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
6.5 |
5.3.1.4 – 5.3.1.5 |
Equipment calibration and metrological traceability |
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6.5.1 |
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General: Specify requirements |
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6.5.2 |
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Equipment calibration: Procedure – conditions – records – verification – correction factors – risk |
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6.5.3 |
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Metrological traceability of measurements results:
Documented
– unbroken chain of calibrations – traceability - SI – other
means – genetic reference sequences – |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
6.6 |
5.3.2.1 – 5.3.2.2 – 5.3.2.3 – 5.3.2.4 – 5.3.2.5 – 5.3.2.6 – 5.3.2.7 |
Reagents and consumables |
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6.6.1 |
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General: Processes |
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6.6.2 |
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Reagents and consumables – receipt and storage: Storage – manufacturer specification – monitor environmental conditions – verify adequacy receiving facility |
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6.6.3 |
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Reagents and consumables – acceptance testing: Verify performance – each reagent/new formulation/new lot/shipment – before use/before release results |
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6.6.4 |
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Reagents and consumables – inventory management: Establish inventory management system – segregate accepted from not inspected or accepted |
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6.6.5 |
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Reagents and consumables – instruction for use: Instructions – available- used according manufacturer specifications |
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6.6.6 |
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Reagents and consumables – adverse incident reporting: Investigated - reported - procedure – manufacturer recall |
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6.6.7 |
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Reagents and consumables – records: Records of performance – in-house additional information |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
6.7 |
4.4.1 – 4.4.2 |
Service agreements |
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6.7.1 |
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Agreements with laboratory users: Procedure – informed of changes – records of reviews |
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6.7.2 |
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Agreements with POCT operators: Service agreements - Specify and communicate responsibilities and authorities |
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6.8 |
4.5.1 – 4.5.2 – 4.6 |
Externally provided products and services |
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6.8.1 |
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General: Ensure – externally provided products and services – suitable - Collaborate other departments or functions |
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6.8.2 |
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Referral laboratories and consultants: Communicate -requirements for procedures/examinations/reports, management critical results, personnel qualifications –referring laboratory responsible – list |
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6.8.3 |
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Review and approval of externally provided products and services: Procedures – records – define, review and approve requirements - criteria qualification, selection, evaluation - referral of samples – conform requirements before use – actions from evaluations |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
EN ISO 15189: 2022 § 7: Process requirements
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
7.1 |
4.2.1 - 4.11 - 4.14.6 |
General |
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7.1 |
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General: Potential risks – residual risk – mitigation process – monitoring & evaluation – opportunities to improve - framework |
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7.2 |
4.4.1 - 5.4.1 – 5.4.2 -5.4.3 – 5.4.4.1 – 5.4.4.2 – 5.4.4.3 – 5.4.5 – 5.4.6 – 5.4.7 |
Pre-examination processes |
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7.2.1 |
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General: Procedures - accessible |
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7.2.2 |
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Laboratory information for patients and users: Available info – sufficiently detailed – locations, opening hours and contact info – procedures for requesting and collection – scope & time – advisory services – patient consent – factors – complaint process |
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7.2.3 |
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Requests for providing laboratory examinations: 7.2.3.1 General agreement – sufficient info – unequivocal traceability – requester – examinations – advice 7.2.3.2 Oral requests procedure – documented confirmation – given time |
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7.2.4 |
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Primary sample collection and handling: 7.2.4.1 General procedures – available info – deviation – potential risk and impact – periodically review 7.2.4.2 Information for pre-collection activities info and instructions – patient preparation – type and amount – order – special timing – clinical info – labelling for unequivocal identification – criteria for acceptance and rejection 7.2.4.3 Patient consent informed consent – special procedures – patient’s best interest 7.2.4.4 Instructions for collection activities safe, accurate and clinically appropriate – verification of identity – meeting pre-examination requirements – collection – labelling & unequivocal link – identity person collecting & collection date/time – separating and dividing – stabilization and storage conditions – safe disposal |
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7.2.5 |
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Sample transportation: Instructions – packaging – time between collection and receipt – temperature interval – specific requirements – integrity – health risk – notification & action – periodically evaluate |
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7.2.6 |
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Sample receipt: 7.2.6.1 Sample receipt procedure Unequivocal traceability – criteria for acceptance and rejection – date and time of receipt – identity person receiving – evaluation by authorized personnel – urgent samples – original sample 7.2.6.2 Sample acceptance exceptions Process – compromised samples – incorrect identification – sample instability – incorrect storage/handling temperature – inappropriate containers – insufficient sample volume – acceptance – final report – nature – advising caution |
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7.2.7 |
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Pre-examination handling, preparation, and storage: 7.2.7.1 Sample protection Procedures – appropriate facilities – securing 7.2.7.2 Criteria for additional examinations requests Time limits 7.2.7.3 Sample stability Time specified and monitored |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
7.3 |
4.9 - 4.14.2 - 5.5.1.1 – 5.5.1.2 – 5.5.1.3 – 5.5.1.4 – 5.5.2 - 5.5.3 – 5.6.1 – 5.6.2.1 – 5.6.2.2 – 5.6.2.3 – 5.6.3.1 – 5.6.3.2 – 5.6.3.3 – 5.6.3.4 – 5.6.4 |
Examination process |
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7.3.1 |
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General: Methods validated for intended use – performance specifications – up to date and readily available – follow established procedures – identity recorded – periodically evaluate examinations – clinically appropriate |
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7.3.2 |
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Verification of examination methods: Procedure – before introducing – performance specifications – extent of verification – authorized and competent personnel – review – repeat verification when revision – records |
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7.3.3 |
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Validation of examination methods: Laboratory designed/developed methods – use outside intended scope – modified validated methods – as extensive as necessary – confirm specific requirements – intended use – extent – authorized and competent personnel for review – changes - records |
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7.3.4 |
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Evaluation of measurement uncertainty: Evaluated and maintained – compare – documented – regular review – where MU not possible/irrelevant – available – inquiries – sources – qualitative results – verification/validation |
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7.3.5 |
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Biological reference intervals and clinical decision limits: Defined and communicated – periodical review – changes - characteristic |
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7.3.6 |
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Documentation of examination procedures: Extent necessary – consistent application – language – available – abbreviated document – product instructions – validated change – implications – document control |
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7.3.7 |
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Ensuring the validity of examination results: 7.3.7.1 General Procedure – monitoring validity – recorded – trends and shifts – planned and reviewed 7.3.7.2 Internal quality control (IQC) IQC procedure – specified criteria – intended clinical application – lot-to-lot reagent or calibrator variation – third-party IQC material - fit for intended purpose – stability – matrix – close to patient samples – clinically relevant challenge – if not available – frequency – recorded data – trends and shifts – IQC data review – acceptability criteria – regular intervals – timeframe – prevent the release – IQC fails 7.3.7.3 External quality assessment (EQA) Monitor performance – procedure – personnel who routinely perform – EQA’s programme(s) selected – target values – if not available or suitable – EQA data review – acceptability criteria – time frame – appropriate action – clinical impact 7.3.7.4 Comparability of examination results: Different methods or equipments – different sites – procedure – record the results – periodically review – impact – inform users |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
7.4 |
4.5.2 - 4.13 – 5.4.7 - 5.7.1 – 5.7.2 - 5.8.1 – 5.8.2 – 5.8.3 - 5.9.1 – 5.9.2 - 5.9.3 |
Post-examination processes |
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7.4.1 |
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Reporting of results: 7.4.1.1 General Accurately, clearly, unambiguously – in accordance with examination procedure – info for interpretation of results – procedure for delay – retaining of all associated info 7.4.1.2 Results review and release Review – prior to release - authorized personnel – evaluation – responsibility – procedure 7.4.1.3 Critical results reports Critical decision limits – notification – documented actions – escalation procedure 7.4.1.4 Special considerations for results Simplified reporting – all info available – preliminary report – records for oral reporting – accuracy of communication – special counseling – use of anonymized results 7.4.1.5 Automated selection, review, release and reporting of results Procedure – specified criteria – validated criteria – review – verification after change – results for manual review – rapid suspension 7.4.1.6 Requirements for reports Documented reason for omission – patient identification – laboratory – user – primary sample – examinations – method – results and units – biological reference intervals – clinical decision limits – R&D examinations – identification review and authorization – preliminary results – critical results – end 7.4.1.7 Additional information for reports Time primary sample collection – time of report release – examinations by referral laboratory including name – consultants – interpretation and comments – sample quality and suitability – discrepancies – misinterpretation 7.4.1.8 Amendments to reported results Procedure – reason – additional document or data transfer – awareness – completely new report – record when no capture of revision |
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7.4.2 |
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Post-examination handling of samples Time length – conditions – identification – additional examinations – storing – located and retrieved - discarting |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
7.5 |
4.9 |
Nonconforming work |
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7.5 |
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Nonconforming work: Process – laboratory activities – examination results – responsibilities and authorities – specified actions – halting examinations – evaluation of clinical significance – decision – revision when necessary – resumption – corrective actions - records |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
7.6 |
5.10.1 – 5.10.2 –5.10.3 |
Control of data and information management |
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7.6.1 |
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General: Access to data and info |
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7.6.2 |
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Authorities and responsibilities for information management: Specified authorities and responsibilities – maintenance – modification – ultimately responsible |
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7.6.3 |
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Information systems management: Validated & verified – changes – authorized – documented – before implementation – documentation readily available – implemented - cybersecurity – environment – manual recording and transcription – integrity – recording of system failures – calculations and data transfer |
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7.6.4 |
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Downtime plans: Planned process – automated selection and reporting |
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7.6.5 |
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Off site management: Off-site – external provider - comply |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
7.7 |
4.8 – 5.4.2 |
Complaints |
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7.7.1 |
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Process: Description of the process – tracking and recording – appropriate actions – publicly available |
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7.7.2 |
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Receipt of complaint: Confirm – resolve – gathering info – acknowledge receipt – outcome – progress reports |
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7.7.3 |
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Resolution of complaint: Investigation and resolution – discriminatory actions – person not involved - impartiality |
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7.8 |
4.1.1.4 |
Continuity and emergency preparedness planning |
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7.8 |
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Continuity and emergency preparedness planning: Emergency situations – identification – coordinated strategy – periodically tested – planned response capability – info and training – respond to actual emergency situations - action |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
EN ISO 15189: 2022 § 8: Management system requirements
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
8.1 |
4.1.2.3 – 4.2.1 – 4.2.2.2 – 5.1.5 |
General requirements |
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8.1.1 |
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General: establish, document, implement and maintain a management system – fulfilment requirements this document – responsibilities – objectives and policies – documented information – actions - continual improvement – evaluations and internal audits – management review |
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8.1.2 |
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Fulfilment of management system requirements: Quality management system – fulfilment requirements clauses 4-7 and 8.2-8.9 |
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8.1.3 |
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Management system awareness: Aware – objectives policies – contribution to effectiveness management system – consequences |
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8.2 |
4.1.2.1 – 4.1.2.4 – 4.2.2.1 – 4.2.2.2 – 4.3 |
Management system documentation |
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8.2.1 |
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General: establish, document, and maintain objectives and policies – ensure acknowledgement and implementation |
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8.2.2 |
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Competence and quality: Objectives and policies – address competence, quality and consistent operation |
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8.2.3 |
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Evidence of commitment: Evidence of commitment – development and implementation management system – continually improvement |
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8.2.4 |
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Documentation: All documentation, processes, systems and records – included in, referenced from or linked to management system |
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8.2.5 |
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Personnel access: Access – management system documentation - applicable for responsibilities |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
8.3 |
4.3 |
Control of management system documents |
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8.3.1 |
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General: Control – internal and external documents |
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8.3.2 |
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Control of documents: Uniquely labelled – adequacy – periodically reviewed – available – revision status – protection – obsolete documents – retained |
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8.4 |
4.13 – 5.9.3 |
Control of records |
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8.4.1 |
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Creation of records: Establish and retain legible records – created – activity – affects quality |
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8.4.2 |
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Amendment of records: Traced – previous versions- original and amended data – date |
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8.4.3 |
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Retention of records: Implement procedures – retention times – retrievable examination results – available – legible |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
8.5 |
4.11 – 4.12 – 4.14.6 |
Actions to address risks and opportunities for improvement |
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8.5.1 |
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Identification of risks and opportunities for improvement: Identify – risk and opportunities for improvement |
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8.5.2 |
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Action on risks and opportunities for improvement: Actions – proportional to potential impact – record decisions and actions – effectiveness |
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8.6 |
4.11 – 4.12 – 4.14.3 – 4.14.4 |
Improvement |
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8.6.1 |
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Continual improvement: Improve effectiveness – identify opportunities – actions – risk assessments – communicate |
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8.6.2 |
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Laboratory patients, user and personnel feedback: Seek feedback – analyzed – improvement management system – records – communication |
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8.7 |
4.9 – 4.10 – 4.14.8 |
Nonconformities and corrective actions |
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8.7.1 |
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Actions when nonconformity occurs: Respond – immediate action – address consequences – determine cause – evaluate need corrective action – implement action – effectiveness – update risks and opportunities – change management system |
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8.7.2 |
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Corrective action effectiveness: Appropriate to effects – mitigate identified cause |
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8.7.3 |
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Records of nonconformities and corrective actions: Records – non-conformity – cause – actions – effectiveness |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
Normelement 2022 |
Normelement 2012 |
Omschrijving |
Evaluatie |
8.8 |
4.14.1 – 4.15.4 – 4.14.7 |
Evaluations |
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8.8.1 |
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General: Conduct evaluations – planned intervals – meet requirements- |
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8.8.2 |
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Quality indicators: Monitoring quality indicators – planned – periodically reviewed |
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8.8.3 |
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Internal audits: Internal audits – planned intervals – provide information on management system – programme |
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8.9 |
4.15.1 – 4.14.3 – 4.15.2 – 4.15.4 |
Management reviews |
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8.9.1 |
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General: Review - planned intervals- suitability – adequacy - effectiveness |
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8.9.2 |
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Review input: Recorded – evaluations – previous management review – fulfilment objectives – outcomes evaluations/monitoring – feedback – quality assurance – effectiveness – external providers – interlaboratory comparison – POCT- other |
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8.9.3 |
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Review output: record decision and action – effectiveness- improvement – provision required resources – any change – time frame – communication to personnel |
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Belangrijkste bekeken documenten:
Algemene beschrijving van de vaststellingen inclusief de verwijzing naar eventuele tekortkomingen:
EN ISO 15189: 2022 § Annex A: Additional requirements for Point-Of-Care testing
Normelement 2022 |
Normelement ISO 22870 |
Omschrijving |
Evaluatie |
A.1 |
4.1.1 – 4.1.2.1 – 4.2.2.1– 4.2.2.1 - 4.4 – 5.1.4 |
General |
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General: Additional requirements POCT- responsibilities- selection devices- training – quality assurance – management review |
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A.2 |
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Governance |
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Governance: Responsible- monitor accuracy and quality – service agreements with all locations – clinical approval – POCT areas |
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A.3 |
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Quality assurance programme |
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Quality assurance programme: Person responsible – review – conformity with this document |
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A.4 |
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Training programme |
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Training programme: Person – appointed- develop/implement/maintain training programme |
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Referentie |
Evaluatie |
Conclusie |
BELAC 2-001 (verwijzing accreditatie) |
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XXXXX 0-000 (accreditatiescope : vast versus flexibel – slapende activiteiten) |
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XXXXX 0-000 (beleid en leidraden betreffende herleidbaarheid van meetresultaten) |
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BELAC 0-000 (xxxxxxxxxxxxx-xxxxxxxxxxxx (PT): leidraden deelname en evaluatie van performantie) |
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BELAC 2-405 NGS (richtlijnen voor NGS analysen voor hematologische en solide tumoren) |
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XXXXX 0-000 MED (bijkomende wettelijke verplichtingen) |
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