1.

0 INTRODUCTION:
In our today’s country, radiation protection has turned out to be one of the most
alarming issues in majority of our radiological diagnostic centres. Though radiography is
gaining wide acceptance in nearly all part of the continent, it is equally important that
the radiation protection of staffs and patients is taken into consideration and this is the
sole responsibility of the radiographer operating the x-ray equipment. For this reason,
quality control was considered one of the tools in optimizing best practice in the area of
radiation protection of both the patient and the staff and also in maintaining the
production of consistently high-quality diagnostic radiographs. (Martin, 2007).
According to ICRP (1991), there are two basic principles of radiological
protection. There are; justification of the practice and optimization of protection. In the
area of optimization of protection, there is considerable scope for reducing doses to
patient without any loss of diagnostic information, but the extent to which the
measures available are used varies widely. Optimization of radiation protection does not
necessarily mean the reduction of doses to the patient or by operating in the absence
of a demonstrable threshold for stochastic effects but by trade-off between the benefits
of dose reduction and the costs of achieving these reductions. A number of factors
facilitate this trade-off. One of such factors is the quality control measurements and
practices of the department. (Saure and Hagemann, 1995).
This quality control as noted by Maccia and Moores (1997), involves a
quantitative and qualitative measurements and test of the performance of x-ray
equipments, programs and practices of that diagnostic centre. Hence, in instituting a
good quality control system in our x-ray department, a quality control program which
will monitor the basic components of the imaging process at a low cost through the use
of simple, inexpensive tools and minimal staff time must be put in place. This quality
control will now determine their adequacy in terms of production of high-quality
diagnostic radiographs and also evaluates their contribution to all the radiation
protection practices therefore outlining their role in the optimization of the radiation
protection of that centre.

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2.0 DEFINITION OF TERMS
Quality Control (QC): These are specific actions designed to keep measurable
aspects of the process involved in manufacturing a product or providing a service within
specified limits. These actions typically involve measurement of a process variable,
checking the measured value against a limit, and performing corrective action if the
limit is exceeded. (CRCPD Pub., 2001).
Quality Assurance (QA): These are planned and systematic actions that provide
adequate confidence that a diagnostic x-ray facility will produce consistently high
quality images with minimum exposure of the patients and healing arts personnel. The
determination of what constitutes high quality will be made by the facility producing the
images. Quality assurance actions include both quality control techniques and quality
administration procedures. (CRCPD Pub., 2001).
Quality Control Program: allows a facility with limited resources and personnel to
monitor the basic components of the imaging process at a low cost through the use of
simple, inexpensive tools and minimal staff time.
Quality Assurance Program: Is an organized entity designed to provide quality
assurance for a diagnostic radiology facility. The nature and extent of this program will
vary with the size and type of the facility, the type of examinations conducted, and
other factors. (CRCPD Pub., 2001).
Optimization: Optimization in the field of diagnostic radiology simply means any
process or procedure which ensures that doses due to appropriate medical exposure for
radiological purposes are kept as low as reasonably achievable (ALARA) consistent with
obtaining the required diagnostic information, taking into account economic and social
factors. (IAEA Pub., 2004).
Cost-Effectiveness: Chesney (1981) defined Cost-Effectiveness as “the ratio of
spending to the efficiency of production that follows the result”. It compares the relative
expenditure (costs) and outcome (effects) of two or more courses of action.

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3.0 AIMS AND OBJECTIVES:
The main aim and objective of this colloquium is to promote awareness creation
about the practical implementation of quality control protocols and image quality
evaluation by consistently implementing simple and inexpensive actions such as the use
of appropriate screen/film combination, use of secondary radiation grids when
necessary, etc.
It also aims to create pools of expertise in the area of radiation protection of
patients, hence alleviating the dangerous practices of unnecessary irradiation of our
patients.
A further objective of this research seminar is to offer assistance and guidance to
an imaging scientist implementing and operating a quality assurance program any in
diagnostic radiology department across the globe.

4.0 SIGNIFICANCE OF QUALITY CONTROL:

All medical facilities using x-ray equipment, from a simple intra-oral dental unit to
an image intensified special procedure system, will benefit from adopting a good quality
control program because;
I. It will monitor the imaging process from start to finish revealing potential
problems that may otherwise go unrecognized and achieving reduction of
dose to patient and consistent production of high-quality diagnostic
radiographs.
II. It will also form a learning process for those taking part and will also provide
them with tools and practical protocols which can be used in the
implementation of a national quality control program in diagnostic radiology
in future.
III. Another most important benefit of a close control of the x-ray department
can be summarized by saying that, the overall cost-effectiveness of the
department will be improved. (Chesney, 1981).

3
 Some details which add up to improved cost-effectiveness includes;
a. The number of repeated radiographs is reduced.
b. The rate of flow of patients through the department is improved.
c. The department’s ability to meet the demands made upon its services is
raised.
d. Quality of radiograph produced is higher.
e. Standardization of the radiographic results is achieved and maintained.
f. The reliability efficiency of automatic processors and of x-ray equipment is
improved.

5.0 QUALITY CONTROL PROGRAM

According to Stewart (1993), essentially, three steps are involved in a quality
control program. There are;
i. Acceptance Testing: These are test conducted on every new x-ray facilities
e.g. the x-ray machine, cassettes, intensifying screens, grids, to name but a
few. This test is carried out prior to it clinical usage to show if the equipment
is performing within the manufacturer’s specification. This test must be done
by someone other than the manufacturer or his representative.
ii. Routine Performance Evaluation: With use, these x-ray equipments
deteriorate. This necessitates the periodic quality control evaluation of these
equipments. That is, these are the quality control tests conducted on these
equipments to see if the equipment will meet predestined requirements.
iii. Error Corrections: When these equipment performances are not optimal or
do not meet predetermined requirements, or errors found after the quality
control test has been conducted, actions are taken to effect corrections on
them.

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5.1 General Consideration:
An adequate quality control program for any individual facility will depend on a
number of factors which include, but may not necessarily be limited to, items such as
the type of procedures performed, type of equipment utilized, and patient workload.
This program is developed under the guidance and supervision of a medical physicist
qualified in this area of expertise by education, training, and experience.

5.2 Equipment Log:

An individual equipment log should be maintained on each x-ray unit in the
department. This equipment log must be kept at some convenient location where
anyone using the facility (physicians, technologists, physicists, service engineer, etc.)
can get ready access. The log should contain;
1. Equipment Data Specifications
a. Technical specifications, including tube loading charts.
b. Equipment operating instructions.
c. Detailed identification of major components of the system
including name, serial number, and date of installation.
2. An outline of the applicable quality control program.
3. A log of the quality control test results.
4. A record of service on the equipment including a description of system
malfunctions and description of what service was carried out. The
service record should also include identification of the individual
performing the service and the date.

5.3 Recording Test Data:

All quality control test data should be recorded on standardized forms. It is
suggested by AAPM (1981), that each institution develops its own forms suitable to its
own needs.
1. The use of standardized forms will assure that all of the required data will be
obtained.

5
 2. Forms should be filed as part of the room log.
3. The charting of trend data is a recommended procedure which will allow easy
identifications of variation with time. This is of particular value in the case of
film processors.

5.4 Conditions of the X-Ray Equipment:

5.4.1 Mechanical Integrity: As noted in ICRU Report 54 (1996), a general
observation of the diagnostic system should be made. Key items to look for are
the presence of loose or absent screws, bolts, or other structural elements that
may have been improperly installed or have worked loose due to use. The
functioning and operation of meters, dials, and other indicators like the pilot
lights should be checked.
5.4.2 Mechanical Stability: To obtain a diagnostic quality radiograph, it is important
to minimize patient motion. The availability and adequacy of patient support
devices such as the table or immobilizing devices should also be checked. ICRP
Pub. 60 (1991) added that, it is equally important to check the reproducibility of
positioning of the source and image receptor that may be indicated or controlled
by physical marks or detents. A check of the accuracy of angulations scale should
also be made.
5.4.3 Electrical Integrity: The external condition of the high voltage cables should
also be observed. Check to make sure that the retaining rings at the termination
points are tight and that there are no breaks in the insulation. (ICRU Report 54,
1996). It is important to observe the "lay" of the cables, how they are being
hanged, so that they don’t interfere with tube positioning.
5.4.4 Alignment and SID: Source to image receptor distance (SID) indicators should
be checked. The consistency between multiple SID indicators (indicators on the
tube support and the collimator) should be verified. The accuracy of these
indicators should also be verified with a tape measure. Verification of proper grid
installation should be made. This check should also include a verification of the
alignment of the x-ray source and the center of the grid.

6
5.5 The Radiograph As A Quality Control Tool:
Patient’s radiographs are also considered one of the quality control tools of which
they are being checked on periodic basis and should be factored into any
departmental evaluation program.
5.5.1 Rejected Films Analysis: Rogers (2008) defined Film Reject as “a film deemed
useless and discarded with another film being taken” and A Repeat Film as “a
film retaken to provide extra/missing diagnostic information sent with the original
for reporting”.
Film Reject Analysis according to Suleiman and Showalter (1984) are
periodic assessment and checks on rejected films as well as the accepted ones
usually on monthly intervals so as to identify the problem, determine it cause
and find solutions to it, all aiming at reduction of film reject rate.
The causes of rejection of films are analyzed according to the following;
- Too dark, too light (under/over exposure)
- Positioning/Collimation errors
- Patient movement
- Processing errors
- Others
Reference data should also be assigned to this analysis e.g. date/time, operator
ID code, room, exam type, reject or repeat, etc.
5.5.2 Accepted Films Analysis: Good practice should always question the adequacy
of radiographs of less than optimal quality for their acceptability in making a
diagnosis. Repeating a procedure to get a film of optimal quality is often not
necessary and should be evaluated in terms of the radiation exposure and cost
of the retake. Since one should expect to find films of less than optimal quality in
a departmental file, an analytic review of these films should be made on a
regular basis.

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6.0 FACTORS IN OPTIMIZATION OF CONVENTIONAL RADIOGRAPHY
The formation of image of the body involves interplay between many different
factors. To achieve the correct balance between patient dose and image quality, it is
necessary to understand the way in which images are formed, and to know the factors
that influence the image quality and the radiation dose received by the patient, so that
appropriate options can be selected. These factors include;

6.1 Screen/Film Combination:

The most important factor in the optimization of conventional radiography is the
choice of screen/film combination. (Martin, 2006). For a screen-film typed film, the x-
ray film is sandwiched between two screens inside a light-tight cassette. Each screen
has a layer of a fluorescent phosphor, such as calcium tungstate or gadolinium
oxysulphide, which converts x-ray photons into visible light photons. The spectral
emission of the phosphor must be matched to the sensitivity of the film. This therefore
means that the wavelength of light emitted by the phosphor of the intensifying screens
must be within the range of wavelengths of light to which the films is sensitive to and
will record as latent image. (Maccia, 1995). Hence, blue light and green light emitting
phosphors must be used with monochromatic and orthochromatic films respectively.
Martin (2006) continued that, the thickness chosen for the phosphor layer is a
compromise between radiation dose and image quality. That is, a thick film will have
high efficiency in the conversion of x-rays to light but with blurred image. But thin
screens results in better resolution but requires higher radiation exposure.
Hence, in choosing a screen/film combination, factors such as; the spectral
sensitivity of the film, the sensitivity of screen/film which is quantified in terms of speed
index, image contrast and range of exposure levels to be produce; etc must be put into
consideration. (Gray and Winkler, 1983).

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6.2 Exposure Control:
To produce an image on a film with an acceptable level of contrast, the exposure
must be within a relatively narrow range of doses. This is to say that all exposures must
be as low as reasonably achievable. (ICRP Pub. 60, 1990).
Two major factors according to Martin and McKenzie (1993) are involved in the
quantity of radiation produced by the tube. These are; the tube potential difference
(kVp) and the beam filtration. They also noted that, the exposure factors used will be
optimized through the experience of the radiographers and exposure charts employed
for each X-ray unit. The charts provide a guide to the best factors for different
examinations for a patient of standard build. But however, adjustments will need to be
made for patients of different sizes.

To achieve a consistent exposure level, an automatic exposure control (AEC)

device is usually employed in fixed radiographic imaging facilities. This comprises a set
of X-ray detectors behind the patient that measure the radiation incident on the
cassette. The detectors are usually thin ionization chambers. Exposures are terminated
when a pre-determined dose level is reached, thereby ensuring that similar exposures
are given to the image receptor for imaging patients of different sizes. The important
parameter involved in radiographic image formation is optical density, so film is used in
setting up the AEC to give a constant optical density. (Shrimpton and Jones, 1984).

6.3 Scattered Radiation And Use Of Low Attenuation Components:

Scattered radiations are produced when x-rays are attenuated at angles different
from the incident rays by the body tissue. These scatter is increased with increase
thickness of body part examined, e.g. skull, pelvis, lumbar spine examinations.
As noted in IAEA Publication (1995), radiation scatter has adverse effects on our
radiographs which are;
i. Decreases the light transmitting ability of our film.
ii. Decreases slightly the sharpness of the recorded detail.

9
 iii. Increases the random background noise of the film and all these will
result in
iv. a reduction in the contrast of the film.
The amount of scattered radiation can be reduced by means of an anti-scatter
grid. (Bauer, 1998). The grid consist of a plate containing thin strips of lead lying
perpendicular to the plated surface, which are sandwiched between a low attenuation
inter-space material which are radiolucent materials made of either aluminium or
polyester. X-ray photons are more likely to be attenuated by the lead strips. (Sandborg
and Carisson, 1993).
Secondary radiation grids are not used for examination of the body parts but
only parts intended to produce scatter maybe as s result of increase in the tube
potential difference (kVp).

6.4 Beam Collimator and X-Ray Projection:

Collimation of the X-ray beam is an important factor in optimization. Good
collimation will both minimize the dose to the patient and improve image quality,
because the amount of scattered radiation will increase if a larger volume of tissue is
irradiated.
Hart and Shrimpton (2000) noted that, collimation is particularly important in
pediatric radiography since the patient’s organs are closer together and larger fields are
more likely to include additional radiosensitive organs. Collimation in most cases
depends on the technique of the radiographer, but regular quality control by checking
that the X-ray beam and the field from the light beam diaphragm are accurately aligned
is important, particularly for mobile equipment.

6.3 Film Processing:

The final stage in the production of a radiograph is processing the film. If
processing conditions are not optimal, the film will require a higher radiation dose in
order to provide an acceptable film density. Chemicals should be changed regularly, and
the processing conditions, such as temperature and development time should be

10
carefully optimized. A system of quality control that involves checking temperatures of
processing chemicals and carrying out sensitometry, involving development of a test
strip of film exposed to a range of light levels ensures optimal performance. (BIR Pub.
2001). These checks should be carried out daily to monitor performance in terms of film
density, contrast and background fog level. The performance levels of processors that
have a relatively low workload need to be monitored carefully.
Gray and Winkler (1983) noted that, film processing affects the film density;
therefore, it influences the speed index. Thus, the measurements of the characteristic
curve for a film will also reveal problems with processing. If a film is taken with
optimized processing, it can be considered the reference standard. Checks can then be
made by comparing future results with the reference standard to identify any
deterioration.

7.0 RECOMMENDED QUALITY CONTROL TESTS

This section describes the recommended quality control tests that should be
carried out in a radiological diagnostic centre. The frequency and brief procedure of the
test is also described in this section.
To successfully carry out a good quality control tests on our x-ray equipments,
many test tools and equipments of which some could be made by the user are required.
Such items include; test phantoms, mesh patterns, alignment fixtures and timing tools,
densitometers, etc. Other test tools, such as the test cassette, require calibration and
adjustment which is feasible only when a quantity can be made.
According to CRCPD Pub. 01-5 (2001), the recommended guidelines and steps
on implementing a good quality control test on our x-ray facilities are as follows;

7.1 Processor Quality Control (Sensitometry):

Objective: The objective of this test is to determine if the processor is working
optimally.
Frequency: This test should be carried out daily, prior to processing patient films

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Required Equipment: Includes; a) Sensitometer b) Dedicated box of control film c)
Densitometer.
Steps:
1. Expose the control film with the sensitometer.
2. Develop the film.
3. Determine the average optical density of the mid-density step and record it on a
form.
4. Determine the average optical density difference and record.
5. Measure the background optical density (base + fog) and record. Verify that the
measured values are within a suggested optimal performance criteria.
Corrective Action:
The tests should be repeated if the values are outside the performance criteria. If, after
repeating, the results are still out of limits, look for processing problems and contact the
processor service supplier.

7.2 System Constancy Test:

Objective: To assure that the radiographic system is operating consistently.
Suggested Performance Criteria: Optical density on test film within 1 step of
comparison film.
Frequency: This test should be carried out monthly and after service of the equipment
Required Equipment: Include; Aluminum step wedge, quality control cassette, film,
densitometer
Steps:
1. Set the x-ray unit to the technique factors and source-to-image distance
2. Place the step wedge on the loaded QC cassette on the table top and center the x-
ray beam to the step wedge.
3. Collimate to the edges of the step wedge.
4. Make an exposure of the step wedge and process normally.
5. Using the densitometer, compare the optical densities for Steps 4 through 8 with the
comparison film.

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6. Record your results on the monthly quality control checklist.
Evaluation: Compare the current film with the comparison film. If the densities are not
within 1 step of the comparison film, constancy has not been maintained and clinical
images should not be taken until the problem has been identified and corrected.
Corrective Action: Repeat the test to confirm results. Verify that the processor is in
control. Contact your x-ray and processor service engineers.

7.3 Daily And Weekly Darkroom Quality Control

Objective: To keep the darkroom clean and processing optimized.
Frequency:
Daily - Check developer temperature
Daily - Check developer, rinse, fixer levels
Daily - Clean processor feed tray, counter tops
Weekly - Clean darkroom
Required Equipment: Include; non-mercury thermometer, mop, non-abrasive, liquid
cleaning solutions damp, lint-free cloths.
Steps:
Daily: If manual processing, developer temperature must be measured with non-
mercury thermometer for correlation with the time-temperature chart.
If auto processing, measure the temperature with a non-mercury thermometer
to verify that the developer is operating within the temperature range
established by the manufacturer, and that the display, if applicable, is accurate.
It may not be necessary to physically measure the temperature daily if the
processor passes the daily QC test
Daily: If manual processing, replenish following the chemistry manufacturer
guidelines. Replace rinse water.
If auto processing, follow the processor manufacturer recommendations
regarding replenishment.
Daily: Clean processor feed tray and counter top.
Weekly: Damp mop darkroom floor. Clean counters, cabinets, and anywhere else

13
 dust may accumulate. Clean film hangers.
Corrective Action: If automatic processor can not be maintained at its optimal
operating temperature, call processor service supplier.

7.4 Radiographic Illuminators Quality Control:

Objective: Is to ensure radiographic illuminators (Viewing boxes) are clean and light
levels are kept consistent throughout. A difference in luminance can create confusion
and may effect accurate interpretations.
Suggested Performance Criteria: Illuminator lights are the same “color” and
luminance, and illuminator surfaces are kept clean.
Frequency: This test should be carried out monthly.
Required Equipment: Glass cleaning supplies
STEPS:
1. Clean surface of illuminator.
2. If a bulb or tube fails, it is best to replace all of them.
3. Record results on the monthly quality control checklist.

7.5 Visual Checklist:

Objective: To assure that all components of the radiographic x-ray system indicator
lights, displays, and mechanical locks and detents are working properly and that the
mechanical rigidity and stability of the equipment is optimum.
Suggested Performance Criteria: Each of the items listed in the QC Visual Checklist
should pass or receive a check mark. Items not passing the visual check should be
replaced or corrected as soon as possible.
Frequency:
1. Quarterly
2. After service or maintenance on the x-ray system.
Steps:
1. Collimator light brightness and cleanliness.

14
 Determine if light is functioning and is clearly defined under normal operating
conditions, without visible dust or foreign matter shadows.
2. Collimator beam limiting devices (BLDs) available and used.
If unit provides variable collimation, determine that they are functioning correctly
and smoothly. If manual beam limiting devices are being used, assure they are
sufficient for confining the x-ray beam to the area of clinical interest. Assure that
both types are being used correctly.
3. Locks and detents operable.
Check to make sure all locks and detents are functioning as intended. Assure
that the x-ray tube maintains its position at the clinically used angles.
4. Boom smoothness of motion.
Determine if boom moves easily without catches or interruptions.
5. Grid condition and operation.
If grids are being used, check that grid lines, grid cutoff, or grid damage is not
visible on films. Assure that grid is properly positioned, centered to central ray
and if a focused grid is being utilized that the correct focal distance if being used.
6. Condition of cables.
Inspect all cables for frayed coverings, kinks, and determine that cables are free
from friction from other objects.
7. Tube or generator oil leakage.
Visually inspect areas around x-ray tube and generator for oil or abnormal
collection of dust attaching to oil leaks.
8. Cassettes and screens condition.
Cassettes and screens should be cleaned regularly. Check screen condition for
dust particles, scratches, and areas of discoloration. Assure screens are properly
fitted and attached to cassettes. Check cassette latches to make sure they are
functioning properly and are not broken. Cassettes and screens should be
replaced if necessary.

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9. Loaded cassette storage.
Determine that loaded cassettes are stored in an area that is properly shielded
from radiation to prevent exposure. They should be stored off the ground and
kept free from dust.
10. Control panel indicators.
Assure all control panel switches, lights, and meters are functioning correctly.
11. Technique chart.
Make sure a technique chart is available, current, and appropriate for all
procedures normally performed.
12. Patient view ability.
Determine that means are provided to permit continuous observation of the
patient during the x-ray exposure.
13. Exposure switch placement.
Assure the exposure switch is mounted in such a way that exposure can only be
made with the operator in a protected area during the entire exposure. If unit is
portable or mobile without a portable protective barrier, assure cable on
exposure switch provides means for the operator to be at least nine feet from
the tube housing during the exposure.
14. Lead aprons, gloves, collars, etc.
Assure proper items are available and stored correctly without bends or folds. If
abnormal areas are found, complete procedure 13.
Corrective Action: Missing items from the room should be replaced as soon as
possible. Malfunctioning equipment should be reported to the x-ray service engineer for
repair or replacement as soon as possible.

7.6 Repeat Analysis:

Objective: To identify ways to minimize patient exposure and reduce costs by
addressing higher than normal repeat rates.
Suggested Performance Criteria: The criteria associated with repeating a film is
subjective. There is no good way to determine what the repeat rate should be. Each

16
facility should decide on its own, but should strive for a repeat rate of no greater than 5
to 7%.
Frequency:
1. Ongoing tracking of films
2. Quarterly data analysis
Steps:

1. Determine the reason for film repeat as compared to the categories listed on the
data sheet.
2. Record these numbers on the Repeat Analysis Form.
3. Determine the total number of repeated films and the total number of films
exposed. The overall repeat rate is the total of repeated films divided by the total
number of films exposed during the test period.
4. By dividing the number of repeats per category by the total number of repeated
films, a facility can determine the repeat rate per category.
Corrective Action: The percentage of repeats should guide the facility to focus their
efforts to those areas needing the most attention. For example, films that are too light
or too dark may be due to processing problems, equipment problems that require repair
or re-calibration, or technique charts may need updating.

7.7 Film and Chemical Storage:

Objective: To assure film and chemistry quality is maintained and inventory is rotated
on a first in, first out basis.
Frequency: Quarterly
Steps:
1. Maintain inventory so first in is first out.
2. Maintain the temperature and humidity to manufacturer recommendations.
3. Follow the chemistry manufacturer guidelines for replacement and disposal.
4. Record results on the Quarterly QC Checklist.

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Corrective Action: If storage conditions exceed manufacturer’s recommendations,
take the necessary steps to resolve the problem.

7.8 Artifact Evaluation:

Objective: To identify and minimize artifacts that may obscure clinical findings on the
radiographs.
Suggested Performance Criteria: No roller marks or artifacts
Frequency:
1. Quarterly
2. When artifacts are noted
Required Equipment: Cassette and film, marking Pen, illuminator.
Steps:
1. Place the loaded cassette in the bucky or cassette holder. Expose the film to obtain
anoptical density of about 1.00 (5-10 mAs, 60 kVp)
2. After unloading the cassette in the darkroom, mark the direction of the film
transport with a pencil and develop as usual.
3. Using the same cassette, repeat Steps 1 and 2, but this time mark and run the film
perpendicular to the previous one.
4. Using a radiographic illuminator, compare the films, comparing any artifacts seen on
them to their direction of travel through the processor.
5. Record results on the Quarterly QC Checklist.
Analysis: If artifacts are present, compare the artifacts with respect to the direction of
film transport. If the artifacts run parallel on both films with respect to transport
direction, they are from the processor. If they are perpendicular to each other when
viewed with respect to transport direction, they are from somewhere else in the
imaging chain.
Corrective Action: Find, identify, and correct the source of artifacts

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7.9 Intensifying Screen Cleaning Procedure:
Objective: To assure that screens and cassettes are free of dust and dirt particles that
may degrade image quality.
Suggested Performance Criteria: Minimize artifacts on films from screens or
cassettes.
Frequency:
1. Quarterly or semiannually (depending on workload and amount of dust in the
environment)
2. When a problem is noticed
Required Equipment:
1. Screen cleaner (as recommended by manufacturer)
2. Lint-free gauze pad or cloth, or camel’s hair brush.
3. Canned air (available from photographic supply store)
Steps:
1. Visually inspect the condition of the intensifying screen.
2. Dust the screen with the camel's hair brush and canned air.*
3. If foreign material (e.g. dirt, developer solution) cannot be readily removed
with the camel's hair brush, use liquid screen cleaner.
4. After cleaning with manufacturer approved cleaners, screens should be
allowed to air-dry, standing vertically, before returning the cassette to use.
5. Record results on the Quarterly QC Checklist.
Corrective Action: If the screen shows signs of cracking, fading, or discoloration it
should be evaluated for replacement.
Assure that the canned air used to clean the screens is "clean" air. If the air
contains moisture, oil, or other contaminants, you may be introducing artifacts or
damaging the screen.

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7.10 Darkroom Integrity or Fog Test:
Objective: To determine and minimize the amount of darkroom fog.
Suggested Performance Criteria: An optical density increase of 0.05 or less.
Frequency:
1. Semiannually, with each type of film used clinically
2. After bulb or filter replacement
3. After changing or adding types of film
Required Equipment: Includes; opaque material (manila folder), watch or timer,
attenuation block (aluminum step wedge, phantom, acrylic block) to create a medium,
optical density of about 1.0 on the film, densitometer.
Steps:
1. Load a cassette with film and place on a flat surface.
2. Center the attenuation block and expose the film using an x-ray technique that
will result in an optical density of about 1.0 after the film is processed.
3. With the safelights on, place the exposed film on the work area in the darkroom.
Cover half the film with opaque material, bisecting the latent image parallel to
the long axis of the film.
4. Leave exposed film on the counter for 2 minutes, then process as usual.
5. While waiting 2 minutes for darkroom fog test, look for any sources of
extraneous light. Any light leaks identified should be repaired as soon as
possible.
6. Inspect the processed film. If there is no discernible delineation between the
shielded and unshielded sides of the film, there is no fog problem.
7. If a line is evident, measure the optical densities of both sides of the line with
the densitometer. If the density difference is greater than 0.05, corrective action
should be taken.
8. Record results on the Semiannual QC Checklist.
Corrective Action: Repeat the test with the safelight off. If the results remain the
same, the problem may be caused by a light leak or extraneous light. If the fog level

20
disappears, the fog was due to the safelight and remedial action must be taken to
correct the problem.
Possible Sources Of Darkroom Fog:
- Safelight filters (old or compromised) - Radios
- Safelight housing - Fluorescent light afterglow
- Safelight too close to work area - Light leaks
- Light bulb of incorrect wattage or type - Suspended ceilings
- Ancillary indicator lights on processor - Timers
- Any place there is a hole cut in the wall
- Excessive ambient light through the tinted viewing windows of daylight loading
systems.

7.11 Screen-Film Contact Test:

Objective: To assure that optimum contact is maintained between the screen(s) and
film in each cassette.
Suggested Performance Criteria: No large areas (> 2 cm in diameter) of poor
contact.
Frequency:
1. Acceptance testing for new cassettes
2. Annually
3. As needed, if reduced image sharpness is suspected
Required Equipment:
1. Brass or copper mesh screens (1/8 inch or 3 mm spacing). The mesh should
be as large as the largest cassette to be tested. The mesh can be placed
between two thin sheets of acrylic or cardboard to protect it.
2. Densitometer
Steps:
1. Load cassettes to be tested and let rest for approximately 15 minutes to allow
trapped air to escape.
2. Place the cassette on the table and collimate the beam to the cassette size.

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3. Place the wire mesh on top of the cassette and expose the cassette. (Suggested
technique factors are: 5-10 mAs, 50 kVp; 2 mAs, 70 kVp; or 3-5 mAs, 60 kVp).
4. Process the film. The optical density of the area between the wires of the mesh
on the film should be between 1.5 and 2.0.
5. View the film on a in a room with low ambient lighting. Stand 6 to 8 feet away
from the illuminator to evaluate the film.
6. Areas of poor contact will appear as dark areas on the film.
7. Record results on the Annual QC Checklist.
Corrective Action:
Large areas (>2 cm in diameter) of poor contact may indicate the need for corrective
action. Clean the cassettes and retest. Areas of poor contact around the periphery of
the cassette may indicate faulty latches or worn seals on the cassettes. If the area of
poor contact is not eliminated by cleaning, consider replacing the cassette.

7.12 Collimator Test:

Objective: To assure that the light field accurately defines the x- ray field.
Suggested Performance Criteria: The light and x-ray field misalignment does not
exceed 2% of the source-to-image distance (SID) in either the length or the width of
the film.
Frequency:
1. Annually
2. After service or maintenance on the x-ray system (e.g., changing the light bulb)
Required Equipment: Includes; i) 8 coins, ii) measuring tape.
Steps:
1. Place a 10 x 12 inch (24 x 30 cm) loaded cassette at a known SID (e.g., 28 inches).
2. If possible, adjust the field size to 6 x 8 inches (15 x 20 cm). The field must be
smaller than the film. If your system is not equipped with a variable collimator,
attach a beam limiting device (BLD) that provides a field size smaller than the
cassette.
3. Place the coins.

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 4. Expose (65 kVp, 4 mAs) and develop the film. If field edges are not well defined,
adjust techniques accordingly and repeat this step.
5. Measure the distances between the light (where the coins touch) and x-ray fields for
all coin locations.
6. Add differences for each set of coins along and across the film, and divide each set
of differences by the SID (Example: (1.5" along table / 28")(100) = 5.38% and (0.5"
across table / 28")(100) =1.79%).
7. Percentage differences greater than 2.0% in either direction should be corrected as
soon as possible.
8. Using the same exposed film, determine the center of the x-ray field (darkened
portion of film) using a straight edge.
9. In the same manner, determine the center of the film.
10. Measure distance between the two centers and calculate the difference as a
percentage of the SID. If the percentage difference is greater than 2.0%, corrective
action is necessary.
11. Measure the dimensions of the x-ray field on the film. If the difference between the
indicated and measured field size exceeds 2% of the SID, corrective action is
required.
12. Record on the Annual QC Checklist.
Corrective Action: Malfunctioning equipment should be reported to the x-ray service
engineer to correct the problem.

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7.13 Protective Device Integrity Check:
Objective: To assure that the various protective devices such as lead aprons, gloves,
gonadal shields, and thyroid collars provide
optimal protection when positioned appropriately.
Suggested Performance Criteria: No breaks in lead lining of protective garments.
Frequency: Annually
Required Equipment: Lead aprons, gloves, gonadal, and thyroid shields
Steps:
Option 1: If an image intensified fluoroscopy unit is available, this is the preferred way
to inspect the aprons, gloves, and collars.
1. Lay out the item to be checked on the table.
2. Examine the entire item using the fluoroscope.
3. Record results on the Annual QC Checklist.
Option 2: If an image intensified fluoroscopy unit is not available:
1. Closely inspect each item for kinks and irregularities.
2. Take a radiograph of suspect areas.
3. Process the film and look for breaks in the lead lining.
4. Record results on the Annual QC Checklist
Corrective Action: Any item displaying breaks in the lead lining should be replaced.

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5.0 CONCLUSION:
In conclusion, based on patient dose measurements, comparison with reference
values, assessment of image quality, the introduction of quality control and corrective
actions, if needed, and re-evaluation of patient doses and image quality, has
demonstrated its effectiveness for optimization of radiological protection program.
Finally, a ‘culture’ of regular patient dose measurements, film reject analysis, and
image quality assessment need to become part of diagnostic radiology.

6.0 RECOMMENDATION:
From all the information outlined in our colloquium, it has been proven beyond
reasonable doubt that quality control programs and protocols form an essential part of
the optimization process. Therefore, such programs covering physical and technical
parameters associated with the types of x-ray examination being carried out needs to
be instigated in every medical x-ray facility. For that reason, we strongly recommend
that all state radiation control personnel should be encouraged to promote quality
control as a proven means to reduce doses of exposure, increase and maintain
diagnostic image quality, and limit health care costs.

25
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