Abstract

Objective: The objective of this project was to find out whether QA tests are being carried out for the x-
ray equipment at the CWM and Lautoka Hospitals and furthermore to determine whether the general
radiographic x-ray machines, equipment accessories and darkrooms satisfy the QA requirements and are
compliant with WHO standards. One more objective was to identify the leading factors contributing to
rejected films.

Subjects and Methods: In this experimental study design, 7 quality assurance tests were carried out on
the 7 operating x-ray machines and three darkrooms in the two major hospitals in Fiji. Questionnaires
were given out and rejected films were analyzed in regards to the cause.

Results: Out of the 7 machines tested in CWM and Lautoka hospital, 42% of the machines were not
producing the kVp value, 100% of the machines had efficient timers, 57% of machines were not giving
correct densities and 29% had incorrect light/x-ray beam alignment. It was also noted that 100% of the
cassettes had correct film/screen contact and 67% of the darkrooms had inefficient safelights. Through
the reject film analysis, it was found that the average number of films rejected in two months in CWM
was 1055 and in Lautoka, 525. It was also concluded that Monday had the most number of films
rejected.

Conclusion: From the results we gathered, it was noted that most of the machines that were tested
needed some form of recalibration. No form of QA program is being used and there is no Quality
Assurance Committee. All these lead to a high number of rejected films which meant unnecessary
radiation to the patient, wastage of resources and increase in the workload of the radiographer.

1|Page
Aim

To assess the standard of current Quality Assurance (QA) practice in the Radiology department at the
Colonial War Memorial Hospital (CWM) and Lautoka Hospital.

2|Page
Objectives

 To find out whether QA tests are being carried out for the x-ray equipment at the CWM and Lautoka
Hospitals.
 To determine whether the general radiographic x-ray machines, equipment accessories and
darkrooms satisfy the QA requirements and are compliant with WHO standards.
 To identify the range of factors contributing to rejected films.

3|Page
Introduction

According to Blinov, Kuzin and Leichenko (1992), Quality Assurance (QA) is ‘the procedures and
techniques carried out to guarantee the functional quality of various devices’. In this case the devices
assessed would be the x–ray machines. X-ray departments use expensive equipment to produce good
quality medical x-ray image and these equipment can only be maintained by implementing some form
of a QA program.

An adequate diagnostic quality assurance (QA) program involves periodic checks of the components in a

diagnostic x-ray imaging system together with frequent analysis of rejected films. The optimum QA

program for any individual facility will depend on a number of factors which include types of equipment

utilized and radiographers’ workload.

As student radiographers, observations were made that a substantial number of resources were wasted
in the form of rejected radiographs, chemicals, et cetera. Furthermore, the radiographers are unaware
of the causes of this wastage of resources and there is no standardized QA program that could identify
and rectify these problem areas. In addition, no previous published research concerning QA had been
conducted in Fiji.

This research is carried out in two of the major hospitals in Viti Levu; CWM and Lautoka Hospitals. There
are a total of five general x-ray rooms and three darkrooms in CWM Hospital while in Lautoka Hospital;
there are four general x-ray rooms and two darkrooms.

According to Lloyd (2001), there are a total of 38 recommended QA tests for the radiology department.
For this research because of financial and time constraints, a total of 7 QA tests were conducted to
assess whether the machines were operating in accordance to WHO standards.

4|Page
 The tests for x-ray equipment were:
 Accuracy of kVp test (Appendix 5)
 Accuracy of timer test (Appendix 6)
 Constancy of radiation output at different mA settings (Appendix 7)
 The tests for accessory equipment included:
 Light beam alignment test (Appendix 8)
 Shutter efficiency test (Appendix 9)
 Film/Screen contact test (Appendix 10)
 The test for the darkrooms was:
 Safe light efficiency test (Appendix 11)

This research will determine whether the QA practice at CWM and Lautoka hospitals are up to WHO
standards, identify if there are equipment faults encountered in the Radiology department and highlight
some of the common causes of rejected films through reject film analysis. Furthermore, this research
will recommend corrective measures on any of the faults identified to help improve the standard of care
given to the patients and ensure that the x-ray machines are properly maintained and safely operated.

5|Page
METHODOLOGY

6|Page
Methodology

Literature Review
The standard of x-ray machines plays an important role in ensuring a quality health care to the patient
and a limit to the wastage of resources. This can be done by implementing some form of QA program
which in turn will ensure that the standard of the machines are maintained.
In a comparative study done by Kharita et al (2008) to evaluate the national quality assurance program
for x-ray diagnostic radiology in Syrian government hospitals clearly show the need for quality assurance
in a radiology department set up. In this study two periods were covered; one from 1986 to 1998 with
52 hospitals and 149 x-ray machines and the second period was from 1999 to 2005 with 41 hospitals
and 95 x-ray machines. They noted that most x-ray machines were within the acceptable performance
but a few needed recalibrations for some parameters. In the second period, a considerable
improvement of 50% was noted. The study concluded that the improvement was due to the
establishment of an effective National Regulatory Authority in Syria in 1998 that introduced and
enforced the quality assurance requirements for x-ray equipment as part of licensing process and to the
relatively newer x-ray machines covered in the second period.

Next, the aims and implications of the implementation of QA programme were addressed by Henshaw
E.T (1990) who stated that x-ray departments are expensive to equip and run. His paper illustrated how
a quality assurance programme would help to minimize the wastage of resources. In the article the aims
of a QA programme was defined and the implications arising from these aims were discussed. They
identified the pitfalls of a QA programme in radiology as; firstly the tendency to carry out a large
programme and acquire a considerable amount of data so that the original aims are obscured, secondly
the possibility of carrying out tests which are expensive to perform and are not cost effective, thirdly the
failure to adapt the contents of the QA programme to the ever changing needs of the local department.
He concluded that the impact of the components of the QA programme on standard of work of x-ray
department is:
 resource management through film reject analysis
 patient dose measurement
 equipment inspection programme
 equipment maintenance programme
 Training and education of staff.

7|Page
Furthermore, the implementation of QA programme was addressed in the form of knowledge of
equipment quality and safety assessment. This was highlighted by Vladimirov and Kepler (2008), in a
survey of medical equipment and safety assessment in Estonian health care institutes by the Training
Center of Medical Physics and Biomedical engineering (BMTK) was done. Through this survey, the center
provided technical expertise and disseminating knowledge of modern equipment maintenance
principles, affordable quality control and constancy check, increasing quality awareness of users, and
introducing quality management practices and procedures in health care organizations. A total of 150
machines were tested with the following tests; main supply test, electrical safety test, high voltage
generator test, radiographic x-ray tube test, radiographic table test, bucky wall stand test, fluoroscopic
tube test, patient entrance dose test, x-ray image intensifier test. From this survey, they concluded that
quality control programme provides a necessary part of the quality assurance program in health care
institutes. Some typical QC issues that need to be discussed in detail are; compatibility of methods,
optimization of the number of QC test and estimation of uncertainty in each QC measurement.

Moreover, the need for QA program was discussed in the form of optimization in radiography by Martin
(2006) discussed the factors that needed to be considered in optimizing the performance of
radiographic equipment. He stated that the most important factor is the choice of film/screen
combinations and the preparation of automatic exposure control devices to suit its characteristics.
Another factor stated which could reduce patient dose was the use of copper filtration to remove more
low energy x-rays. The conclusion was that regular surveys of patient dose and comparisons with
diagnostic reference levels that provide a guide representing good practice enable units for which doses
are higher to be identified. The causes were investigated and changes made to address them.
Application of these methods has led to a gradual reduction in doses in many countries.

The importance of quality control and preventive measures was also emphasized by Sungita et al (2006)
who stated that “without appropriate quality control and preventive measures for x-ray machines in
place, the benefits of reduced dose to the patient and early diagnosis will not be realized”. They
conducted four QC tests on 196 x-ray units in Tanzania. Their findings showed that 59% of the machines
failed the kilovoltage test, 57% failed the timer accuracy test, 60% failed the beam alignment test and
20% failed the radiation leakage test. Also, only 13% passed the preventive measures test; 53% o the
units were defective, and 34% were out of order. The results of the PM findings made the government
introduce a rehabilitation project to service x-ray units and replace the defective ones.

8|Page
The journal by Mihic et al (2008) defined quality assurance as ‘ensuring adequate clinical diagnostic
information together with the least possible exposure of patient to radiation (ALARA principle) at the
lowest costs in quality assurance’. Furthermore they have stated that in Republic of Croatia, there has
been no form of QA program in diagnostic radiology. Reasons why QA program has not been
implemented in Croatian Health Care System vary from lack of educated staff with adequate measuring
equipments to absence of obligatory legal acts and poor financial situation.

Production of good quality radiographs and having a good radiation protection also depends on the
quality and stability of equipment, Porubszky (2008) in her article on ‘Quality Control Test of Diagnostic
Radiology Equipment in Hungary and its Radiation Protection Aspects’ stated that acceptable quality of
equipment is necessary from the point of view of radiation protection of patient. In the European Union
Directive 97\43\EURATOM it states that radiation protection of patients require good practices of
quality assurance. This regulation has in turn made the ministry of Health of Hungary to pass out a
degree that all new diagnostic x-ray equipment should undergo acceptance testing and QA programmes
must be carried out under the surveillance of radiation health authority.

Furthermore, according to Chikiridin and Zakharova (1996), the diagnostic accuracy of information
content of x-ray photographs and radiation dose on patients and medical personnel significantly depend
on the initial settings and stability of x-ray diagnostic equipment. Therefore diagnostic x-ray equipments
must be carefully configured so that it serves patients better and there is decrease consumption of x-ray
films, developing reagents and other expendable materials.

Importance of quality assurance was further emphasized by Eze et al (2008), where an audit done of
rejected films was done in the radiology department of a University Teaching Hospital to find out the
causes, number, percentage and sizes of rejected films. The total number of x-ray films rejected for a
two year period was collected. A radiologist and three radiographers viewed and analyzed the films for
their causes. The conclusion for the audit was that through rejected radiographs, radiographers work
load is increased as well as that of support staff. The waiting room may be congested and waiting time
increased. The cost of repeats is high. Rejected- repeated films analysis is cheap, simple, practicable,
easy to interpret and effective indicator of quality assurance of radiology departments.

9|Page
Muhogora et al (2008) related two factors to Quality Control (QC) programme. First, poor image quality
produced in radiographic examinations and secondly, the significant variation in radiation dose levels to
patients of similar size undergoing the same type of radiographic examinations. In this research, 12
countries in Africa, Asia and Eastern Europe, covering 45 hospitals was surveyed in relation to the rate of
unsatisfactory images, image quality grade, and causes for poor quality. Poor image quality produced in
radiographic examinations gives rise to tremendous amount of wastage of resources due to reports
being done and this results in unnecessary radiation exposure to patients. There is loss of diagnostic
information on the radiographs and increased social costs in addition to the economic costs of health
care. In addressing the aforementioned concerns, establishing of a Quality Assurance programme
focusing on image quality and patient dose was done, image quality improvement up to 16% was seen
and patient dose reduction ranging from 1.4% to 85% was achieved. Thus quality assurance programme
is an optimization tool of patient dose and poor image quality.

Next, this study presents acceptance testing and routine quality control of general radiographic x-ray
equipment in Island during 2006 and early 2007 L Gray et al (2008). It shows that 100 general
radiographic x-ray systems testes within Island, 73% of them failed to meet the required QC
requirements, whereby one or more faults were identified. This review of the QC result highlights the
need to perform comprehensive acceptance and routine testing of the systems.

A study carried out by No Egbe et al (2007) in some Nigerian hospitals also highlighted the significance
of quality control. In this study the image quality of abdominal radiographs was done to establish a
baseline for the development of QC programmes in all Nigerian hospitals. Evaluation of 210 plain
abdominal radiographs produced between 2002 and 2004, in 3 Nigerian hospitals was done. From the
210 radiographs studied, 107 satisfied all the criteria for good images. The study found 6.61% of the
total number of films was rated as ‘rejectable’. The journals findings ‘underscore the need for
implementing QC programmes using the results of this study as a baseline’

Further on, Périard M.A, Chaloner P (1996) discusses that an “ineffective QA program can lead to poor
radiographs that can impair diagnosis, increasing operating costs and contribute to unnecessary
radiation exposure both to patients and staff’. It suggests that there should be “a requirement that each
diagnostic x-ray facility have in place a basic QA program to control the quality of diagnostic images”. A
successful QA program requires that all staff within the radiology department understand the goals set

10 | P a g e
out in the program and take an active part, “for any program lacking genuine interest is unlikely to
produce optimal results and meticulous care is required in this QC program to ensure good quality
radiographs”. Thus QA program helps to minimize hazards and distress to patients and maintain the
radiographic equipment.

An analysis of an image QA program was done by Gothlin & Alders (1985). A reject film analysis before
and after the introduction of a QA program showed a “45% decrease in rejected films”. Through the QA
program changes in equipment and routine was done through increase in the control of film processors
and x-ray generators, new film cassettes and screens and a decrease in the number of film sizes used.
Also supervision of radiographic personnel was done. This helped in “saving costs and increase income
from an increased amount of outpatients corresponded to about 4.5% of the total cost of operating and
maintaining the department”.

Ebisawa et al (2009) also discusses “the QA of radiographic images on the operating conditions of x-ray
equipment is essential for good image quality, accurate medical diagnostics and for prevention of health
professionals and patients to unnecessary doses of ionizing radiation”. An analysis of 1,635 QA
technicians’ reports of health institutions in the State of San Paulo, Brazil, over a seven year period was
done. A significant improvement was found in the percentage of acceptance of the overall parameters
was noted. A parameter such as half-value layer (HVL), which is important for image quality as well as
radiation protection showed significant improvements. “58% of portable x-ray machine equipment
showed HVL values recommended for 80kVp (above 2.3mm Al) in 2000, a percentage that improved to
76% in 2006. Conventional x-ray machines showed an increase of this conformity index from 89% in
2000 to 94% in 2006”. All this improvement was attributed to the enforcement of a QA program, which
resulted in the improvement of diagnostic quality, as well as the reduction of exam repetition and
thereby reducing the patient exposure to radiation.

Schandorf and Tetteh (1998) further indicated “the need to organize the safe use of x-rays in Ghana
through social and economic factors taken into account such as x-ray equipment design and
maintenance”. A survey was carried out through questionnaires and recording forms for a period of
6years, it revealed that there was “no established acceptance testing procedures for newly installed x-
ray equipment, neither institutional level performance checks following major repairs of faulty
equipments, nor routine checks at regular intervals to ensure self-consistency of equipment

11 | P a g e
performances”. The results of the film retake analysis undertaken indicated a need for QA programs to
be taken seriously to avert considerable costs and high patient doses. Therefore, the article also
concluded that “radiographers performing x-ray examination should receive adequate training in the
selection of procedures so as to ensure that doses to patient are as low as reasonably practicable in
order to receive the desired diagnostic objectives”.

12 | P a g e
Study design

A prospective study was carried out with an experimental study design.

Data Collection

Quantitative method of data collection was used in this research:

 Rejected Films
 Each group member was assigned to collect the rejected films from the radiology departments
daily for a period of two months (June – August, 2010). The films were sorted and analyzed
according to the day of reject and their causes.

 Respective codes were allocated to rejected films to de-identify it.

 Questionnaires (see appendix 1)

A total of 24 radiographers from the host hospitals were given a set of questionnaires to answer. The
distribution of the sample size of the participants was as such:

 CWM Hospital (12)

 6 females
 6 males
 Lautoka Hospital (12)
 6 females
 6 males

A consent form (Appendix 2) was given to all participating radiographers prior to the distribution of
questionnaires. The radiographers were informed that their participation was voluntary and that they
had full rights not to participate in the study. Together with the consent form, a plain language
statement (Appendix 3) was handed out which informed the participants about the project. Students
from this group, attached in CWM, distributed the questionnaires to radiographers in CWM while
students attached in Lautoka hospital distributed the questionnaires to Lautoka staffs.

13 | P a g e
 Quality Assurance Tests
Quality Assurance tests were performed on 7 general x-ray machines and 3 darkrooms at the mentioned
hospitals which were operational at the time of this study. The 7 QA tests that were conducted are as
follows:

Tests Reason Expectation

kVp Test To check if the selected kVp is produced or The kVp produced must be within
not +/- 5%

Accuracy of Timer test To check if the machines timer is consistent The no. of spots on the
at the set radiation exposure of 70kV, radiograph should be the same
100mA and 0.1sec

mA Settings To check the reliability of different Film densities obtained will be the
combinations of mA and time setting at same
same mAs.
Light Beam Alignment To check whether the light of the collimator The irradiated area should be less
Test is aligned with the x-ray beam. than 10mm

Shutter Efficiency To see if the shutters are allowing radiation No density should be seen on the
to pass through when they are shut. radiograph

Film/Screen To check if the intensifying screen is in The gauze wire pattern on the
Contact contact with the film so that it does not radiograph should be uniform
decrease the sharpness of the image.

Safelight Efficiency To check if the safelight is working There should be no fogging

efficiently or not i.e. there is no fogging of
the test film.

14 | P a g e
Materials Used

The materials used in this study are the test tools that has been used to carry do the experiments and
are as follows:

Tests Materials
kVp Test kVp meter
X-ray Generator

Accuracy of Timer test Spinning Top

12 x 10” loaded cassette

mA Settings Stepwedge
Lead Rubber
12 X 10” loaded cassette
Densitometer

Light/X-ray Beam Alignment Test 12 x 10” loaded cassette

Paper clips
Lead markers

Shutter Efficiency 12 X 10” loaded cassette

Collimator
Lead Markers

Film/Screen All loaded cassettes

Contact Fine Wire Mesh

Safelight Efficiency 12 x 10” loaded cassette

Lead Strips
Two strips of cardboard
Densitometer

15 | P a g e
Data Entry

All the data obtained from the questionnaires during this research were entered in the Epi-Info
accordingly. The data was then analyzed and appropriate graphs and charts made.

Data obtained from the rejected films were entered in two different charts. One chart had the total
number of rejected radiographs according the date and the week and the other had the number of
radiographers according to different causes.

The data from the QA tests were entered in separate tables and charts according to the test done.

Data Analysis

 The information from the questionnaires were analyzed according to the responses in standard
forms, which included:
 The frequency of QA practiced at these hospitals.
 The range of QA tests practiced in both hospitals.
 Availability of QA committee.

 The results from the QA tests were analyzed in accordance to the equipment faults.

 Rejected radiographs were analyzed using the reject film analysis criteria (Lloyd P. J (2001)) and
were used to identify:
 The weekly distribution of the rejected films.
 The days on which the most number of films are rejected.
 The most common cause of rejected radiographs.
 The number of radiographs rejected as a result of equipment failure.

 The Epi - Info™ (Version 3.5.1) software, a computer program, was used to analyze the data
collected.
 The data collected from the QA tests and the Reject Film Analysis were analyzed and
appropriate charts and graphs were made using Microsoft Excel.

16 | P a g e
Data Storage

 Information obtained in form of hard copies such as questionnaire responses were kept
confidential in a locked cabinet.
 All the information in soft copies was password protected and was only accessible to the
members of the group.
 The information was kept for the duration of research project and discarded carefully so that no
one could access it.

17 | P a g e
DATA

18 | P a g e
Data
CWM Hospital Rejected Film for a Period of Two Months

Monday Tuesday Wednesday Thursday Friday Total

21/06- 42 28 34 24 18 146
25/06

28/06- 26 26 25 21 16 114
02/07

05/07- 29 22 27 24 20 122
09/07

12/07- 44 27 24 32 12 139
16/07

19/07- 34 31 26 33 17 141
23/07

26/07- 45 26 36 24 10 141
30/07

02/08- 38 22 31 29 14 134
06/08

09/08- 30 25 22 26 15 118
13/08

Total Films Rejected – 1055

Table 1 shows the number of rejected films collected each day for a period of two months at CWM
Hospital.

Analysis of Rejected Films of CWM

19 | P a g e
 21/06- 28/06- 05/07- 12/07- 19/07- 26/07- 02/08- 09/08- Total
25/06 02/07 09/07 16/07 23/07 30/07 06/08 13/08

Positioning Error 34 40 29 36 41 31 27 33 271

Movement 13 7 9 12 8 11 8 9 77

Underexposed 52 35 37 41 33 39 29 33 299

Overexposed 46 55 42 41 39 41 45 40 349

Fogging 2 3 1 5 3 4 2 2 22

Equipment Error 6 4 5 4 3 3 1 2 28

Processing 22 12 17 14 12 13 13 11 114

Double Exposure 2 3 1 1 2 2 1 2 14

Table 2 shows the number of rejected films per week in accordance to their causes at CWM Hospital.

Lautoka Hospital Rejected Film for a period of Two Months

20 | P a g e
 Monday Tuesday Wednesday Thursday Friday Total

31/05- 21 12 15 17 14 79
04/06

07/06- 21 18 11 14 16 80
11/06

14/06- 12 11 13 12 11 59
18/06

21/06- 16 10 12 9 11 58
25/06

28/06- 15 15 13 14 12 69
02/07

05/07- 15 14 11 3 11 54
09/07

12/07- 16 13 8 12 16 65
16/07

19/07- 16 14 9 12 10 61
23/07

Total Films Rejected - 525

Table 3 shows the number of films rejected at Lautoka Hospital each day for a period of two months.

Analysis of Rejected Films of Lautoka Hospital

21 | P a g e
 31/05- 07/06- 14/06- 21/06- 28/06- 05/07- 12/07- 19/07- Total
04/06 11/06 18/06 25/06 02/07 09/07 16/07 23/07

Positioning Error 19 13 14 13 16 18 20 15 128

Movement 8 9 4 5 10 3 11 3 53

Underexposed 21 19 25 24 17 27 27 15 175

Overexposed 16 20 21 17 15 19 17 25 150

Fogging - 2 1 - - - 1 2 6

Equipment Error 2 - - - 1 - - 3 6

Processing - 1 1 - 2 3 - 1 8

Double Exposure 2 1 3 - - 1 - 1 8

Table 4 shows the number of rejected films per week in accordance to their causes at Lautoka Hospital.

Questionnaire Analysis

22 | P a g e
Table 5 - Is Quality Assurance practiced in your Department?

CWM Lautoka

Yes 6 10

No 6 2

Total 12 12

Table 6 - How frequently is Quality assurance done on the x-ray equipment?

CWM Lautoka

Weekly 0 3

Monthly 1 2

Yearly 6 7

Total 7 12

Table 7 - Should Quality assurance test be carried out in your department?

CWM Lautoka

Yes 11 12

No 1 0

Total 12 12

Table 8 - Are there sufficient devices (Such as kVp meter, densitometer, and step wedge) for QA test?

CWM Lautoka

Yes 7 11

23 | P a g e
 No 5 1

Total 12 12

Table 9 - Is there any QA committee that is responsible for QA of the machines?

CWM Lautoka

Yes 10 11

No 2 1

Total 12 12

kVp Test

Exposure 1 2 3 4 5 Average

70 62.5 62.1 62.3 62.3 61.9 62.3

24 | P a g e
 80 77.1 76.9 77.3 75.9 75.7 75.4

90 85.1 85.4 84.7 84.7 84 84.8

100 93.4 93.9 96.5 94 94.1 94.6

110 106.1 106.9 107.2 107.4 107.1 106.9

Table 10 shows the kVp readings obtained from the x-ray machine in Room 1 of CWM Hospital.

Exposure 1 2 3 4 5 Average

70 69.6 69.7 69.9 69.6 69.8 69.7

80 78.8 79.9 79.2 79.8 79.3 79.2

90 89.6 89.9 90.1 90.3 90.3 90.1

100 100.6 100.8 100.7 100.7 100.8 100.7

110 111.8 112.1 112 112 111.8 111.9

Table 11 represents the kVp readings of Room 2 in CWM Hospital.

Exposure 1 2 3 4 5 Average

70 70 68.5 70.1 69.8 68.5 69.4

80 78.1 77.5 77.1 76 79.1 79.8

90 88.3 89.1 90.2 90.4 89.7 89.5

25 | P a g e
 100 95.4 97.6 98.6 100.8 99.8 98.4

110 102.1 102.2 102.9 103.6 102 102.6

Table 12 shows the kVp values of the machine in Room 4 at CWM Hospital.

Exposure 1 2 3 4 5 Average

70 70.3 70.2 70.3 70.2 70.3 70.3

80 79.6 80.1 80 80.2 80.3 80.1

90 89.5 89.8 89.7 89.4 90.1 89.7

100 100.4 101.4 100.7 100.7 101.1 100.9

110 110.5 111.3 111.2 111.3 111.2 111.1

Table 13 shows the kVp Values of the machine in Paeds Room of CWM Hospital.

Exposure 1 2 3 4 5 Average

70 74.6 75 74.9 75.1 73.2 74.6

80 78.1 79.2 78.8 78.9 78.9 78.8

90 87.1 88.1 88 87.2 87.4 87.6

26 | P a g e
 100 94.2 94.1 93.9 94 93.8 94

110 99.2 99.5 100 99.6 100.1 99.7

Table 14 represents the kVp values of the machine in Room 1 of Lautoka Hospital.

Exposure 1 2 3 4 5 Average

70 70 70 70.2 70.3 70.1 70.1

80 80.3 80.3 80.3 80.3 80.3 80.3

90 89.2 90.7 89.7 90.3 90.2 90.1

100 100.7 100.6 100.5 100.3 100.2 100.5

110 111 111.4 111.5 111.6 111.5 111.5

Table 15 shows the kVp values of the machines in Room 2 of Lautoka Hospital.

Exposure 1 2 3 4 5 Average

70 70.1 70.3 70.4 70.3 70.5 70.3

80 79.9 79.8 79.5 80 79.9 79.8

90 90 90.4 90.4 90.3 90.9 90.4

100 101.2 101.1 101.2 101 101.2 101.1

27 | P a g e
 110 113.2 112.9 113.1 113.3 113.2 113.1

Table 16 shows the kVp readings of the machine in Room 4 of Lautoka Hospital.

Accuracy of Timer Test

CWM Hospital CWM Hospital Lautoka Hospital

Room 1 Room 4 Room 1

28 | P a g e
 Exposure Number of Dots seen: Number of Dots seen: Number of Dots seen:

1 10 10 10

2 10 10 10

3 10 10 10

4 10 10 10

Table 17 shows the the number of dots obtained on different exposures in different rooms for the
Accuracy of Timer Test.

Constancy of Radiation Output at Different mA Settings Test

Average Density Values at Step 10

Room1 Room 2 Room 4 Paeds Room 1 Room 2 Room 4

CWM CWM CWM CWM Lautoka Lautoka Lautoka

60/125/032 - - - 0.76 - - -

60/100/0.4 0.40 0.52 0.89 - 0.44 0.55 0.52

29 | P a g e
 60/200/0.2 0.45 0.53 1.00 0.84 0.47 0.45 0.56

60/400/0.1 0.49 0.52 0.95 0.81 0.41 0.55 3.02

Table 18 shows the average density values at step 10 of the stepwedge at the host hospitals.

Average Density Values at Step 6

Room1 Room 2 Room 4 Paeds Room 1 Room 2 Room 4

CWM CWM CWM CWM Lautoka Lautoka Lautoka

60/125/032 - - - 3.33 - - -

60/100/0.4 2.36 3.01 3.59 - 2.32 3.04 3.22

60/200/0.2 2.47 3.02 3.65 3.15 2.39 3.05 3.23

60/400/0.1 2.51 3.02 3.4 3.1 2.45 3.05 3.25

Table 19 shows the average density values at step 6 of the stepwedge of CWM and Lautoka Hospitals.

Average Density Values at Step 2

Room1 Room 2 Room 4 Paeds Room 1 Room 2 Room 4

CWM CWM CWM CWM Lautoka Lautoka Lautoka

50/125/032 - - - 4.25 - - -

50/100/0.4 4.01 4.2 4.85 - 4.48 4.35 4.32

50/200/0.2 4.03 4.2 4.72 4.09 4.51 4.34 4.33

50/400/0.1 4.17 4.1 4.90 4.12 4.48 4.35 4.6

Table 20 shows the average density values at step 2 of the stepwedge of CWM and Lautoka Hospitals.

Light Beam/X-Ray Beam Alignment Test

Exposure 1 Exposure 2

Hospita Aligned (< 10mm)/ Not Aligned Aligned (< 10mm)/Not Aligned
l Rooms (>10mm) (>10mm)

CWM Not Aligned FOL 10mm Not Aligned FOL 10mm

Room 1

30 | P a g e
 CWM Aligned FOL 4mm Aligned FOL 4mm

Room 2

CWM Not Aligned FOL 14mm Not Aligned FOL 15mm

Room 4

CWM Aligned FOL 3mm Aligned FOL 3mm

Paeds

Lautoka Aligned FOL 9mm Aligned FOL 9mm

Room 1

Lautoka Aligned FOL 9mm Aligned FOL 9mm

Room 2

Lautoka Aligned FOL 1mm Aligned FOL 1mm

Room 4

Note: The greatest gap from the pins was taken (the maximum value). The Field of Length (FOL) within
10mm had 1% tolerance rate.

Table 21 shows the alignment of x-rays beams to the light of the machines in CWM and Lautoka
Hospitals.

Shutter Efficiency Test

A B

31 | P a g e
 AB Open – CD Closed CD Open – AB Closed

Room Exposure 1 Exposure 2 Exposure 1 Exposure 2

CWM 1 Not efficient. Not Efficient. Efficient Efficient

Radiation Radiation
Leakage of about Leakage of about
1.2cm. 1.1cm

CWM 2 Efficient. Efficient Efficient Efficient

CWM 4 Not Efficient. Not efficient. Not Efficient. Not Efficient.

Radiation Radiation Radiation Radiation

leakage of about leakage of about Leakage of about leakage of about
2.5cm. 2.4cm. 0.9cm. 0.9cm.

CWM Paeds Efficient Efficient Efficient Efficient

Lautoka 1 Efficient Efficient Efficient Efficient

Lautoka 2 Efficient Efficient Efficient Efficient

Lautoka 4 Efficient Efficient Efficient Efficient

Table 22 reflects on the efficiency of the shutters AB and CD of the x-ray machines in CWM and Lautoka
Hospitals.

Safelight Efficiency Test

Darkroom Efficiency of Safelight

CWM-Main No fogging noted

CWM-Paeds Fogging was noted on the test film

Lautoka-Main Slight fogging was noted

32 | P a g e
Table 23 shows the efficiency of the safelights in the darkrooms of CWM and Lautoka Hospital.

33 | P a g e
RESULTS

34 | P a g e
Results

Rejected Film Analysis

CWM Hospital Rejected Film for a Period of Two Months

Figure 1 shows the number of films rejected at CWM Hospital each day for a period of two months i.e.
from 21/06/2010 to 13/08/2010.

35 | P a g e
Figure 2 shows the number of films rejected at CWM Hospital in accordance to their causes.

36 | P a g e
Lautoka Hospital Rejected Film for a Period of Two Months

Figure 3 shows the number of films rejected at Lautoka Hospital each day for a period of two months i.e.
from 31/05/2010 to 23/07/2010.

37 | P a g e
Figure 4 shows the number of films rejected at Lautoka Hospital in accordance to their causes.

38 | P a g e
Questionnaire Analysis

Question 1

Figure 5 shows the percentage of radiographers confirming the practice of QA in CWM Hospital.

Figure 6 shows the percentage of radiographers confirming the practice of QA in Lautoka Hospital.

39 | P a g e
Question 2

Figure 7 shows how frequently QA is practiced at CWM Hospital.

Figure 8 shows how frequently QA is done in Lautoka Hospital.

40 | P a g e
Question 3

Figure 9 shows the percentage of radiographers who wan QA to be practice in CWM Hospital.

Figure 10 shows the percentage of radiographers who want QA to be practiced in Lautoka Hospital.

Question 4

41 | P a g e
Figure 11 shows the percentage of radiographers saying that QA devices are present in CWM Hospital.

Figure 12 shows the percentage of radiographers saying that QA devices are present in CWM Hospital.

Question 5

42 | P a g e
Figure 13 shows the percentage of radiographers confirming the presence of QA committee in CWM
Hospital.

Figure 14 shows the percentage of radiographers confirming the presence of QA committee in Lautoka
Hospital.

QA Test Analysis

43 | P a g e
kVp Test

Figure 15 shows the average kVp readings shown on the kVp meter at different kVp settings of different
rooms at CWM Hospital.

Figure 16 reflects the average kVp readings shown on the kVp meter at different kVp settings of
different rooms at Lautoka Hospital.

Accuracy of Timer Test

44 | P a g e
Figure 17 addresses the accuracy of timer of the x-ray machines of Rooms 1, 2 and Room 4 of CWM
Hospital.

Figure 18 addresses the accuracy of timer of the x-ray machines of Rooms 1, 2 and Room 4 of Lautoka
Hospital.

Constancy of Radiation Output at Different mA Settings Test

45 | P a g e
Figure 19 shows the average densities at the level of step 10 of the all the x-ray machines in CWM
Hospital.

Figure 20 shows the average densities at the level of step 10 of the all the x-ray machines in Lautoka
Hospital.

46 | P a g e
Figure 21 represents the average densities at the level of step 6 of the all the x-ray machines in CWM
Hospital.

Figure 22 depicts the average densities at the level of step 6 of the all the x-ray machines in Lautoka
Hospital.

47 | P a g e
Figure 23 depicts the average densities at the level of step 2 of the all the x-ray machines in CWM
Hospital.

Figure 24 depicts the average densities at the level of step 2 of the all the x-ray machines in Lautoka
Hospital.

48 | P a g e
Figure 25 represents the percentage of machines whose x-ray beams are aligned to the light and also of
those that are not aligned in CWM Hospital.

Figure 26 represents the percentage of machines whose x-ray beams are aligned to the light and also of
those that are not aligned in Lautoka Hospital.

49 | P a g e
Shutter Efficiency Test

Figure 27 represents the percentage of machines in CWM Hospital that has got efficient Shutters AB and
also those that are not efficient.

Figure 28 represents the percentage of machines in Lautoka Hospital that has got efficient Shutters AB
and also those that are not efficient.

50 | P a g e
Figure 29 represents the percentage of machines in CWM Hospital that has got efficient Shutters CD and
also those that are not efficient.

Figure 30 represents the percentage of machines in Lautoka Hospital that has got efficient Shutters CD
and also those that are not efficient.

51 | P a g e
Film/screen Contact Test

Cassettes in CWM Hospital

Size of Cassette Condition of Cassette

17 x 14” Good

14 x 14” Good

15 x 12’ Good

12 x 10” Good

10 x 8” Good

Table 24 reflects on the condition of different sizes of cassettes in CWM Hospital.

Cassettes in Lautoka Hospital

Size of Cassette Condition of Cassette

17 x 14” Good

14 x 14” Good

15 x 12’ Good

12 x 10” Good

10 x 8” Good

Table 25 shows the condition of different sizes of cassettes in Lautoka Hospital.

Safelight Efficiency Test

52 | P a g e
Figure 31 represents the percentage of Darkroom in CWM and Lautoka Hospitals that has got efficient
safelights and also those with not efficient ones.

53 | P a g e
DISCUSSION

54 | P a g e
Discussion

Rejected Film Analysis

Reject film analysis is done to find out the number of films being rejected and what their causes are. It
helps in finding out if the equipments are at fault. It also helps the radiographers to learn from their
mistakes such as exposure differences, positioning errors etc and decreases their work load.
Furthermore, it minimizes the wastage of resources. It is a cheap, simple, practicable, easy to interpret
and effective indicator of quality assurance of radiology departments.

Figure 1 shows the number of rejected films at CWM Hospital per day for a period of two months. The
total number of films rejected for two months is 1055. The highest number of films rejected is 55 which
are on a Monday and the maximum number of films rejected in a week is 146. This graph reflects that
most number of films rejected is on a Monday. One of the reasons of this could be that the
radiographers assigned to the rooms with machines giving different exposure values from the set ones
are not aware of the machine faults. Therefore, they use average values which results in radiograph
being over or underexposed according to the fault. This can be confirmed by Figure 2, which shows that
most films are being rejected due to being overexposed and underexposed. Another reason of this could
be the fluctuation of the kVp produced in accordance to the set kVp values and the different densities as
discussed later.

Figure 3 shows the number of rejected films at Lautoka Hospital per day for a period of two months. The
total number of films rejected for two months is 525. The highest number of films rejected on day is 21
which is a Monday and the maximum number of films rejected in a week is 80. This graph reflects that
most number of films rejected is on Monday. As mentioned above, one of the reasons of this could be
that the radiographers assigned to the rooms with machines giving different exposure values from the
set ones are not aware of the machine faults. Therefore, they use average values which results in
radiograph being over or underexposed according to the fault. Figure 4 shows that most films are being
rejected due to being overexposed and underexposed. Another reason of this could be the fluctuation of
the kVp produced in accordance to the set kVp values and the different densities produced as
mentioned further on.

55 | P a g e
The limitations encountered during this analysis were that the number of rejected films is given in an
approximate value. Observations were made a number of rejected radiographs were removed by
radiographers for personal use or were discarded by them.

Questionnaire

Question 1

Figures 5 and 6 reflect on whether QA tests are being practiced regularly or not in the departments of
CWM and Lautoka Hospitals respectively. According to the figure5, 50% of the radiographers in CWM
said that QA tests are being out whereas the other half commented that QA tests are not practiced.
Also, in figure 6, it is seen that 83% of the radiographers said that QA is being practiced in Lautoka
Hospital. This shows that most of the staffs are not aware whether it is being practiced regularly or not.
This was reflected when interviewing the heads of department at both Hospitals, they commented that
QA tests were only done when a fault was found in the machine and that is was done by the Biomedical
Technicians. It was also noted that a Rejected Film Analysis was done weekly in Lautoka Hospital.

Question 2

Figures 7 and 8 represent the frequency of the QA done in the Departments of CWM and Lautoka
Hospitals respectively. Figure 7 reflects that only 58% of the radiographers responded to this question.
50 % of the radiographers commented that QA is done yearly whereas 8% mentioned that the QA tests
are done monthly. On the other hand, Figure 8 shows a 100% response from Lautoka hospital. 25%
mentioned that QA was done weekly, 17% mentioned that it was done monthly and 58% stated that it
was done yearly. This, as mentioned above, recommends that the radiographers are not sure how
frequently the tests are done.

Question 3

Figure 9 and 10 shows the radiographers view on whether QA should be done in the department or not
at CWM and Lautoka Hospitals respectively. In figure 9, the percentage of radiographers who want QA
to done in CWM Hospital is 92% while the other 8% do not want QA to be done. Figure 10 show that
100% of the radiographers in Lautoka Hospital wanted QA to be done. The percentage of radiographers

56 | P a g e
who want QA to be done commented that it will rectify the machine problems which in turn will reduce
their work load and minimize the wastage of resources.

Question 4

Figures 11 and 12 reflect on the radiographers view whether there are sufficient devices to carry out the
QA test in CWM and Lautoka Hospitals respectively. In figure 11, the percentages of radiographers who
think that there are sufficient devices in CWM are 42% whereas 58% think that the devices are not
available. In figure 12, it was noted that 8% of the radiographers think that sufficient devices are
available in Lautoka whereas 92% think that they are unavailable. This again reflects on the
radiographer’s awareness on the QA in Department and also shows that appropriate devices are
available but not being used.

Question 5

Figures 13 and 14 shows whether there is any QA committee that are responsible for the QA of x-ray
Department in CWM and Lautoka Hospital respectively. In figure 13, 42% of the radiographers in CWM
commented that there is a QA committee whereas 58% said that there are no QA committees. On the
hand, in figure 14, 8% of the radiographers in Lautoka mentioned that there is a QA Committee while
92% mentioned that there is no QA Committee. The 8% Radiographers also commented that the QA
Committee consisted of a radiographer in charge of doing Reject Film Analysis. This again reflects the
lack of awareness of the radiographers about their departments.

kVp Test

This test is carried out to check that the generator is producing the kVp set on the control panel. It is
carried out using a kVp meter. The kVp produced should be within +/- 5% of the set kVp. The tolerance
range for the set kVp used in this experiment is:

 70kVp – 3.5kVp

 80kVp – 4kVp

 90kVp – 4.5kVp

57 | P a g e
  100kVp – 5kVp

 110kVp – 5.5kVp

CWM

Figure 15 shows the average kVp value of Room 1, Room 2, Room 4, and Paeds Room at CWM Hospital.
At 70kVp, the output kVp seen in Room 1 is 62.3kVp which has a difference of 7.7kVp from the expected
value. All the other rooms have kVp settings within the normal range. Room 1 also showed a large
difference at 80, 90 and 100kVp which are 4.6, 5.2, and 5.4kVp respectively. The other rooms are within
the normal range except for room 4 which at 110kVp gives a value of 102.6kVp and has a difference of
7.4kVp from the set value. These values suggest that the generators of the machines in Rooms 1 and 4
are not producing the set kVp values and need to be calibrated by a Biomedical Technician.

Lautoka

Figure 16 shows the average kVp values of Room 1, Room 2 and Room 4 at Lautoka Hospital. According
to the graph, Room 1 has a significant kVp difference at 70, 100 and 110kVp. At 70kVp, it shows a
reading of 74.6kVp which has a difference of 5.4kVp from the set value. As the set kVp increased, the
meter reading of that particular kVp was decreased. The difference of produced kVp at 100 and 110kVp
are 6 and 10.3kVp respectively. All the other rooms were within the normal range. As stated above, the
generators need to be checked by a Biomedical Technician

Accuracy of Timer

This test is done to check the accuracy of the X-ray unit timer i.e. to check if the production of x-rays is
only during the set time or not. A spinning top was used to carry out this test. This test only applies to a
1 or 2 pulse unit. Timers of a 3 phase unit cannot be checked by this method and produces a continuous
line. The accuracy is determined by counting the number of dots on the image formed by the spinning
top. A two pulse unit generates 100 pulse of radiation in 1sec (100 spots on the film). At the selected
0.1sec, 10 dots were formed on film.

Figure 17 depicts how accurate the timer of various x-ray machines of CWM Hospital is. 100% of the
machines tested had efficient timers. CWM Room 1 and Room 4 are double pulse, single phase

58 | P a g e
machines. They show ten dots which signifies that the timer is correct (Appendix 14). It was also found
out that CWM Room 2 is a 3 phase machine therefore this test does not apply to them. Due to the
unavailability of the test tool, timer test was not carried out on these machines.

Figure 18 addresses the accuracy of timer of the x-ray machines of Room 1 of Lautoka Hospital. It was
found out that 100% of the machines tested in Lautoka Hospital also had efficient timers. Room 1 is a
double pulse, single phase machine whereas Rooms 2 and 4 had a 3 phase machine. The timer in Room
1 produced 10 dots on the film at 0.1sec.

If any faults were to be found in timer, a Technician should be called to calibrate the timers.

mA Setting Test

It is the test to check the reliability of the mA and time setting (most importantly the mA). The
photographic effect for a given mAs value should remain constant even though the mA and time factors
may be varied. All other values are constant.

Figures 19 and 20 show the average density values at step 10 of CWM and Lautoka Hospitals
respectively (Appendix 15). Figure 19 depicts that the average densities of CWM Room 1, Room 4 and
Paeds are not within the normal range whereas since Room 2 is a new machine, the densities are with
the normal range and follow the reciprocity law. Figure 20 show that the densities produced by Room 1
machine in Lautoka in also not with the normal range. Rooms 2 and 4 are new machines and follow the
reciprocity law.

Figures 21 and 22 show the average densities of step 6 of the CWM and Lautoka Hospitals respectively.
Figure 21 shows that the average densities of CWM Room 1, Room 4 and Paeds are not within the
normal range and follow the reciprocity law whereas the densities of CWM Room 2 is within the normal
range. Figure 22 represents that the machines in Room 2 and Room 4 of Lautoka hospital produces
densities that are within the normal range whereas Room 1 does not follow the reciprocity law.

Figures 23 and 24 show the average densities of step 2 of CWM and Lautoka Hospitals accordingly
(Appendix 15). Figure 23 shows that the average densities of CWM Room 2 is within the normal range
and follow the reciprocity law whereas the densities of CWM Room 1, Room 4 and Paeds Room do not

59 | P a g e
follow the reciprocity law. Figure 24 depicts that in Lautoka, Room 1 does not follow the reciprocity law
whereas Rooms 2 and Room 4 which has new machines, follow the law.

The Reciprocity Law states that for different combinations of mA and time which has the same mAs, the
density produced is same.

Since the densities were not same in the first test done, several more tests were done to get an average
value. A Technician should be called to check the machine and calibrate it. Also, if the machine is giving a
very large inconsistency, the machines should be stopped from being used.

Light/X-ray Beam Alignment Test

The purpose of the light in a collimator is to allow more accurate collimation of the x-ray beam. The light
must, therefore, coincide with the x-ray beam. The light beam relies on accurate positioning of the light
bulb and angled mirror inside the collimator.

Should either the mirror or the light bulb be dislodged, and then errors in collimation could occur,
resulting in areas of interest being excluded from the field, or too large an area being radiated.

Figure 25 show the percentage of the machine’s with aligned and not aligned light\x-ray beam at CWM
Hospital. Machines with aligned beam are 67% and not aligned are 33%. CWM Room 1 and 4 are not
aligned and shows a FOL of 10mm and 14mm (Appendix 16) respectively at the maximum gap from the
pins which is not within the normal range (< 10mm- 1% tolerance).

Figure 26 shows the percentage of machines with aligned beams. All machines in Lautoka are aligned
and are within the normal range.

If the machines have got a light which is not aligned to the x-ray beam, a biomedical technician should
be called to adjust it.

60 | P a g e
Shutter Efficiency

Closing the shutters in the collimator fully should prevent any radiation from reaching the film. It is
useful for testing radiation safety when discharging capacitor discharge mobiles or making tube warm
up exposures.

Figures 27 and 28 depict how efficient the shutters AB are at CWM and Lautoka Hospitals respectively. It
shows that machines in CWM had 86% efficient shutters and 14% not efficient ones. In Lautoka Hospital,
100% of the machines were efficient. The CWM Room 4 machine has an inefficient shutter with a
radiation leakage of 0.9cm (Appendix 5). All the other machines in both hospitals have efficient AB
shutters.

Figures 29 and30 shows the efficiency of shutter CD is in the machines in CWM and Lautoka Hospital
respectively. It shows that efficient shutters CD in CWM Hospital are 71% and not efficient ones are 29%.
On the other hand, in Lautoka, 100% of the machines had efficient shutters. In CWM, Room 1and 4 the
shutters are not efficient and showed radiation leakage of approximately 1.2cm and 1.1cm respectively
(Appendix 17). The shutters of CWM Room 2, Paeds, Lautoka Room 1, Room 2 and Room 4 are all
efficient.

When this test shows a film that has been radiated upon closing the shutters, a technician should be
called to rectify the problem.

Film/screen Contact test

Good contact between the film and the screen are very important since failure of this can result in
decrease in the sharpness of the image and causes blurring.

Tables 24 and 25 show the different sizes of cassette examined at CWM and Lautoka Hospitals. All the
cassettes that were tested had good film/screen contact (Appendix 18).

If there is any cassette which does not show good contact, it should not be used until repaired or
replaced.

61 | P a g e
Safelight Efficiency Test

A darkroom should be fitted with appropriate safelight. Safelights should be in good condition, have
correct filters to suit the light sensitivity of the film used, have correct voltage and do not leak white
light.

Figure 31 shows how efficient the safelights of the darkrooms in CWM and Lautoka are. The percentage
of darkrooms with efficient safelights is 33% and not efficient safelights are 67%. Fogging was noted on
the test films of the darkroom in Paeds Room in CWM Hospital and the main darkroom in Lautoka
hospital (Appendix 19). The main darkroom of CWM Hospital showed no fogging of the films and is
efficient to use.

If the safelight test is found to be positive, the light should be refrained from further use until it is fixed
since it causes fogging of films and results in the wastage of those films.

62 | P a g e
CONCLUSION

63 | P a g e
Conclusion

From the results of this study, it can be concluded that there is a need for thorough Quality
Assurance practice in the x-ray Departments. It was noted that most of the machines that were
tested needed some form of recalibration. No form of QA programme is being used and there is no
Quality Assurance Committee. All these lead to a high number of rejected films which meant
unnecessary radiation to the patient, wastage of resources and increase in the workload of the
radiographer. The strengths of this research are that majority of the data collected are quantitative
and the same test tools were used to carry out experiments on all machines. However limitations
encountered were the non availability of test tools such as kVp meter, densitometer, step wedge,
spinning top and many more. Also there is no QA committee in both the hospitals to obtain
information from and the recommended tests to be carried were difficult to conduct during working
hours. Furthermore some of the questions from the questionnaires were left unanswered and the
exact amount of repeat films were not collected due to radiographers withholding reject film in
order to avoid being victimized by other colleges during repeat analysis sessions. And added
disadvantages were the non-availability of the proper test tool for three phase generator which
restricted us form caring out the timer test. Lastly, only 7 QA tests were done out of the 38 tests
recommended by WHO manual by Lloyd P.J due to financial and time constraints. The
recommendations from caring out this research are that there is a need to form a QA committee.
This is to ensure that there is QA test Devices available, monitor frequent QA assessment and reject
film analysis. Also most importantly create staff awareness in the form of training to enhance
knowledge and expertise.

64 | P a g e
REFERENCES

65 | P a g e
Reference

Blinov N. N, Kuzin V. S & Leichenko A. I 1992, ‘Quality assurance of equipment in x-ray
diagnostic departments’, Biomedical Engineering, vol. 26, no. 3, pp. 121-123.
Citied on the 20th October, 2010 -
http://www.springerlink.com/content/u512118x2k727781/

CJ Martin, ‘Optimization in general radiography 2006’, Biomedical Imaging and Intervention Journal,
Vol. 7, no. 4, pp. 235-240. Citied on 20 th October, 2010 -
http://www.biij.org/2007/2/e18/e18.pdf

C Schandorf , Tetteh GK 1998, Analysis of the Status of X-ray Diagnosis in Ghana, The British Journal
of Radiology, Vol. 71, no. 85, pp. 1040-1048. Citied on 20 th October, 2010 –
http://bjr.birjournals.org/cgi/content/abstract/71/850/1040

E.G Chikirdin and V.I Zakharova 1996, ‘General Recommendations for Quality Assessment of x-ray
Diagnostic Equipment Performance’, Biomedical Engineering Journal, Vol. 30, no.5, pp. 12-
14. Citied on 20th October, 2010 –
http://resources.metapress.com/pdf-preview.axd?

Eze KC, Omodia N, Okegbunam B, Adewonyi T, Nzotta CC 2008, ‘An Audit of Reject Repeat X-ray
Films as a Quality Assurance Element in a radiology Department’, Oxford Journal, vol. 11,
no.4, pp. 355-363. Citied on 20th October, 2010 –
http://www.ncbi.nlm.nih.gov/pubmed/19320410
Gothlin JH, Alders B 1985, ‘Analysis of an Image Quality Assurance program’, Oxford Journal, Vol. 5,
no. 3, pp 228-230. Citied on 20th October, 2010 -
http://www.ncbi.nlm.nih.gov/pubmed/4029161

Henshaw E.T 1990, ‘Quality assurance in diagnostic radiology- For its sake or that of the
patients’, International Journal for Quality and Health Care, vol. 2, no. 3-4, pp
213-218. Citied on the 20th November, 2010 -
http://intqhc.oxfordjournals.org/content/2/3- 4/213.short

Gray L, Dowling A, Gallagher A, Gorman D, O’Conner U, Devine M, A. Larkin, C.

Walsh & J. L .Malone 2008, ‘Acceptance testing and routine quality control in general
radiography: mobile units and film/screen fixed systems’, Oxford Journal, Vol. 129, no. 1-3,
pp. 276-278. Citied on the 20th October, 2010 –
http://rpd.oxfordjournals.org/content/129/1-3/276.abstract

66 | P a g e
Lloyd P. J, 2001, Quality Assurance Workbook for Radiographers and radiological
Technologists, WHO, Geneva.

M. H Kharita, M.S Khedr, K.M Wannus 2008, ‘A Comparative Study of Quality Control in Diagnostic
Radiology’, Oxford Journal, Vol. 10, no. 2, pp. 45-48. Citied on 20 th October 2010 -
http://rpd.oxfordjournals.org/content/early/2008/04/02/rpd.ncn096.abstract

Maria Lucia Nana Irita Ebisawa, Maria F. A Magon, Yyone M Mascarenhas 2009, ‘Analysis of the
Evolution of Acceptance Indices of Quality Control Parameters for X-ray Equipment in the
State of São Paulo’, Journal of Applied Clinical Medical Physics, Vol. 10, no. 4, pp. 109-125.
Citied on 20th October, 2010 -
http://www.jacmp.org/index.php/jacmp/article/viewArticle/3007/1739
Marihia Suric Mihilc, Tomislav Mestrovic, Ivica Prlic, Dunja Suric 2008, ‘Impotance of Quality
Assurance Program Implementation in Conventinal diagnostic Radiology’, Journal of Radiation
dosimetry, Vol. 32, no. 2, pp. 181-184. Citied on 20th October, 2010 –
http://www.hrcak.srce.hr/file/55495

NO Egbe, DU Eduwem, VC Ikamaise2007, ‘Investigation of image quality of plain abdominal

radiographs in three Nigerian Hospitals’, Biomedical Imaging and Interventional Journal, Vol. 3,
no. 4, pp. 124-135. Citied on 20th October, 2010 –
http://www.biij.org/2007/4/e39/

Périard, M.A, Chaloner P 1996, ‘Diagnostic x-ray imaging quality assurance: An

Overview’, The Canadian Journal of Medical Radiation Technology, Vol. 27, no.
4, pp. 171-177. Citied on the 20th October, 2010 -
http://citeseerx.ist.psu.edu/download/summary?doi=10.1.1.136.9174

Tamás Porubszky, Csaba Váradi, László Ballay,Olivér Turák, Géza Gáspárdy, István Turai,Frédéric Joliot-
Curie 2008, Quality Control tests of Diagnostic Radiology Equipment in Hungary, and its
Radiation protection Aspects, Medical Journal of Physics, Vol. 14, no. 2, pp 99-111. Citied on 20 th
October, 2010 -
http://strony.aster.pl/pdf/pjmpe2008v14n2p099111.pdf

Vladimirov A, Kepler K 2008, ‘Quality Control program of X-ray Equipment in Estonia’, Oxford Journal,
Vol. 5, no. 2, pp. 114-125. Citied on 20 th October 2010 –
http://www.ut.ee/BM/pdf/Vladimirov-Kepler_Trieste2002.PDF

Wilbroad E. Muhogora, Nada A. Ahmed, Aziz Almosabihi, Jamila S. Alsuwaidi, Adnan Beganovic,
Olivera Ciraj-Bjelac, Francois K. Kabuya, Anchali Krisanachinda, Milomir Milakovic, Godfrey

67 | P a g e
 Mukwada, Marie J. Ramanandraibe, Madan M. Rehani, Jalil Rouzitalab, Cyril Shandorf 2008,
‘Patient Doses in radiographic Examinations in 12 Countries in Asia, Africa, and Eastern
Europe: Initial Results f rom IAEA Projects’, American journal of Roentgenology, Vol. 190, no. 6,
pp. 1453-1461. Citied on 20th October, 2010 -
http://www.medscape.com/viewarticle/575467

Yesaya Y. Sungita, Simon S.L. Mdoe, and Peter Msaki 2006, ‘Diagnostic X-ray facilities as per quality
control performances in Tanzania’, Journal of Applied Clinical Medical Physics, Vol. 7, no 4,
pp. 68-79. Citied on 10th October 20, 2010 -
http://www.jacmp.org/index.php/jacmp/article/viewArticle/2291/1296

68 | P a g e
APPENDICES

69 | P a g e
Appendix 1

Sample Questionnaire

ASSESSMENT OF QUALITY ASSURANCE PRACTICE OF DIAGNOSTIC RADIOGRAPHIC EQUIPMENT AT

CWM AND LAUTOKA HOSPITALS IN FIJI

Hospital: CWM Sex: Male

Lautoka Female

Date: __________________

1. Is Quality Assurance practiced in your department?

YES NO

2. How frequently is Quality Assurance done on the x-ray equipment?

WEEKLY MONTHLY YEARLY

3. Do you practice Quality Assurance?

YES NO

4. Are all the x-ray machines (general x-ray machine, bucky, processors) in the department working
efficiently?

YES NO

70 | P a g e
 5. Which machines are complying with WHO standards and which ones are below standards?

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________________________________

6. From the list provided below, identify the Quality Assurance tests that are practiced in your
department. Please tick.
TESTS TICK
Accessory Equipment Tests
Accuracy of scales test
Light beam alignment test
Shutter efficiency test
Light leakage test
Film screen contact test
Film/screen compatibility- color of light emission test
Intensifying screens consistency test
Grid line damage test
Test to detect cracking of lead aprons or gloves
Positioning pads test
Calipers accuracy test
X-ray Equipment Test
Radiation output reproducibility test
Constancy of radiation output at different mA setting test
Accuracy of timer test
Accuracy of kVp test
Alignment of x-ray beam to table test
Check that column is vertical test
Test alignment of x-ray beam to upright bucky
Test accuracy of FFD (SID) scale
Cut thickness test
Pinhole trace test
Operation test
Grid movement test
Cassette centered to middle of bucky test
Film Processing Tests
White light leakage test
White light fogging test
Safelight efficiency test
Cassette pass box radiation proof test
Degree of light fogging of films assessment test
Silver estimation test

71 | P a g e
Hydro retention test

7. Should Quality Assurance tests be carried out in your department?

YES NO

Why? ___________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________________

8. Are there sufficient devices (such as kVp meter, densitometer, and step wedge) for Quality
Assurance tests?

YES NO

9. If no, then should the department buy them?

YES NO

10. Is there any Quality Assurance Committee (QA) that is responsible for Quality Assurance of the
machines?

YES NO

11. If no, then should there be a QA committee in your department?

YES NO

72 | P a g e
 (ALL THE INFORMATION GATHERED FROM THIS QUESTIONNAIRE WILL BE KEPT CONFIDENTIAL AND
USED ONLY FOR THIS RESEARCH)

Appendix 2 SAMPLE RADIOGRAPHERS CONSENT FORM

Fiji School of Medicine

Bachelors in Medical Imaging Science (Year 3)

Suva, Fiji

8th June, 2010

RE: CONSENT FOR PROJECT QUESTIONNAIRES

Dear Sir / Madam

73 | P a g e
This is to inform you that a group of BMIS 3 students (mentioned below) will be conducting a research
test on the topic – The Assessment of Quality Assurance Practices for Diagnostic Radiographic
Equipment at Colonial War Memorial Hospital & Lautoka Hospital in Fiji.

Questionnaires will be handed out to the staff of the radiology department to be filled out. This is a
voluntary act and the decision lies on you, the radiographer.

Please fill the consent form prior to answering the questionnaire. Please be informed that all
information from the questionnaire will be kept confidential.

I Mr. / Ms / Mrs._________________________________ of radiology department of CWM/ Lautoka

Hospital give/ do not give my consent to fill the attached questionnaire.

Your co operation will be highly appreciated. Thank you.

Yours faithfully

Sera Rayasidamu (s080005)

Pritika Chand ( s080207 )

Komal Sami ( s0800804 )

Noa Taucilagi (s070426 )

Moshin Khalil (s080188 )

Appendix 3 Plain Language Statement

ASSESSMENT OF QUALITY ASSURANCE PRACTICE FOR DIAGNOSITIC RADIOGRAPHIC EQUIPMENT AT

CWM AND LAUTOKA HOSPITALS IN FIJI

Thank you for showing interest in this research study. The aim of this research is to assess quality
assurance practices that are carried out in the hospitals. It is being done by the final year BMIS students
together with the MIS faculty.

74 | P a g e
 You have been chosen as a participant due to your position as a radiographer who works in the x-ray
department and use the diagnostic equipment on a daily basis. Your participation is entirely
voluntary and there will be no consequences or change in our attitude towards you if you decline.

 You are requested to answer a set of questions related to Quality Assurance practice. It would
require you to set aside a portion of your time to answer the questions. Using a black or blue pen,
answer to the best of your knowledge and as accurately as you can. I would personally collect the
questionnaires in two days time.

 In participating in this research, you would come to know of your knowledge about quality
assurance practices that are and can be carried out on diagnostic radiographic equipments.
Awareness would be created and new ideas brought forward.

 All information provided by you will be kept confidential as all questionnaires will be kept in a locked
cabinet. Soft copies made will be without any names and will be password protected.

 The information gathered will be analyzed, compiled and put together in a booklet format. A copy of
the published results will be available with the BMIS faculty if you are interested in it. Also a copy
will be forwarded to your department.

For further information or any queries, please contact me on 9311657 or email on s080188@fsm.ac.fj.

Thank you for reading this and now you are invited to complete the questionnaire.

Appendix 5

kVp TEST

Purpose

 To check whether the kVp of the x-ray beam produced by the generator is the same as the kVp
set on the control panel.

Equipment Required

75 | P a g e
  kVp meter.
 Generator to be tested.

Method

 Place the kVp meter in the middle of the X-ray beam at a Film-to-Focus Distance (FFD) of 100cm.
 Collimate to a standard area sufficient to cover the sensor.
 Take reading at 10kVp intervals from 50kVp to the maximum kVp available.
 Use a standard milli-Ampere (mA) and time throughout.
 Repeat this procedure for each tube focus available.

Evaluation

 Compare each kVp reading with the appropriate kVp setting.

 The measured kVp must be within + or – 5kVp or 5%.

Lloyd P. J (2001), pp 60 – 61.

Appendix 6
Accuracy of Timer Test

Purpose:

 To check the accuracy of the x-ray unit timer.

76 | P a g e
Equipment:

 Manually operated spinning wheel.

 One loaded 24 x 30cm cassette.

 Two sheets of lead rubber.

Method:

 Place the cassette on the x-ray table face up.

 Place the spinning top in one quarter of the cassette.

 Cover the other three quarters of the cassette with lead rubber.

 Set a 100cm FFD and collimate to cover the spinning top.

 Set an exposure of 70kV, 100mA and a time of 0.1sec.

 Manually spin the top. After it has settled to a medium speed, make an exposure (it may be
necessary to experiment before starting the test).

 Repeat the process on each of the remaining quarters of the film.

 Process the film.

Evaluation:

 The film will show four images, each having a series of spots forming an arc.

 The distance between the spots is not important as this only represents the speed at which the
disc rotates.

77 | P a g e
  The spots should easily be conducted, so do not allow the spots to complete a circle and
overlap.

 The accuracy of the timer is checked by counting the number of spots.

Lloyd P. J (2001), pp 58 – 59.

Appendix 7

Constancy of radiation Output at Different mA Settings

Purpose:

 To check the reliability of the mA and the radiation exposure time settings.

78 | P a g e
Equipment:

 A step wedge or 10cm water phantom.

 Two sheets of lead rubber.

 One 24 x 30cm cassette.

Method:

 Carry out the procedure used for the reproducibility test with the following exceptions.

 Use three exposures with the same kV and mAs values, but different combinations of mA and
time.

 Suggest exposures:

Exposure 1: 80kV 10 mAs (50 mA 0.2 sec)

Exposure 2: 80 kV 10mAs (100 mA 0.1sec)

Exposure 3: 80kV 10mAs (200 mA 0.05sec)

Evaluation:

 Despite the fact that the mA and time vary, the mAs value remains the same, as does the kV,
therefore all film densities should be the same.

 If the densities are not the same, then it must be assumed that one or more of the exposure
factors are inaccurate or in consistent.

 By varying the mA and kV values as before, it should be possible to identify which of the factors
is at fault.

79 | P a g e
  If the put of step density in each test was the second exposure (100mA), this indicates that the
fault lies with the 100mA setting.

 The kV and time checks should be carried out in conjunction with this test.

Lloyd P. J (2001), p. 58.

Appendix 8

Light Beam/X-Ray Beam Alignment Test

Purpose

 To determine whether the area on the cassette exposed by visible light coincides with the
invisible x-ray beam.

80 | P a g e
Equipment required

 One 24 x 30 cm loaded cassette.

 Alignment set tool.
 Lead marker or ninth coin.

Method

 Make sure the table is level and the central ray is at 90° to the table top.
 Place a loaded cassette on the tabletop face up.
 Set the FFD of 100cm.
 Switch on the collimator light.
 Centre to the middle of the cassette.
 Collimate to within the edge of the cassette, leaving a 3cm boarder all round that is outside the
light field.
 Place the coins in pairs, so that, where the coins touch, coincides with the edge of the light area.
 All four boarders of the light must be marked in this way.
 Place the lead marker within one corner of the light field so that the film can be related to the
light/x-ray field and hence the collimator shutters.
 Make an exposure sufficient to blacken the film.
 Process the film.

Evaluation

 For perfect alignment, the light field (where coins touch) should coincide with the x-ray field.
 The irradiated area must not be greater than the area covered by the light.
 At 100cm FFD the irradiated area must not be more than 10mm smaller that the area covered
by the light. This represents a 1% tolerance.

81 | P a g e
 Lloyd P. J (2001), pp 60-61

Appendix 9
Shutter Efficiency Test

Purpose:
Useful for testing radiation safety when discharging capacitor discharge mobiles or making tube warm
up exposures.

Equipment

82 | P a g e
  On loaded 24 x 30cm cassette.

Method:

 Place the cassette on the tabletop face up.

 Set an FFD of 100cm.

 Set an exposure of approximately 80 kV and 40 mAs.

 Open one set of shutters fully, leaving the other closed.

 Make an exposure.

 Fully close the open shutters and open fully the closed shutters.

 Make another exposure.

 Process the film.

Evaluation:

 Study the film. If shutters are efficient, the film will not have been affected by radiation.

Lloyd P. J (2001), p. 31.

Appendix 10

Film/screen Contact Test

Purpose:

To identify if there is good contact between the radiographic film and the intensifying screen.

Equipment:

83 | P a g e
  Cassette to be tested.

 Test tool ( box of paper clips or sheet of perforated zinc or fine wire mesh, large enough to cover
a 35 x 43cm film, with a square hole, about 10cm from one edge, approximately 2 to 2cm).

 Lead marker, if cassette does not have lead blanked area for patient details.

Method:

 Load the cassette to be tested and place it face up on the tabletop.

 Cover the whole of the cassette with the test tool.

 Set a FFD of 150cm

 Collimate to cover whole of cassette.

 If appropriate, place lead marker in the corner of the cassette face.

 Make an exposure using 50 kV and 6mAs.

 Process the film.

Evaluation:

 If a densitometer is available the film density can be measured at the image created by the hole
in the test tool.

 Inspect the image looking for areas that are lured.

 When using a close mesh wire test tool the poor film/screen contact areas may also have a
higher density.

84 | P a g e
 Lloyd P. J (2001), pp 33 – 34.

Appendix 11

Safelight efficiency test

Purpose

 To ensure that the safelight in the darkrooms of x-ray department do not cause
fogging/blackening of the radiograph.

Equipment required

85 | P a g e
  One 24 x 30cm cassette loaded with new film.
 Two sheets of 24 x 30cm card.
 One timing clock or watch with second hand.
 One 24 * 30cm sheet of lead or lead rubber.

Method 1

 Place cassette face up on the x – ray table.

 Set a FFD of 100cm.
 Cover one third of the cassette with lead rubber, lengthways (area C).
 Collimate to the uncovered area of the cassette.
 Expose the film using a minimum exposure (suggested exposure 45Kv 2mAs).
 Unload the cassette in the darkroom in total darkness.
 Place the film on the workbench.
 Cover one third of the exposed side of the film with the sheet of cards, lengthways (area A).
 Cover area’s B and C of the film, horizontally, with the second sheet of card, except of a 3cm
strip at the top.
 Switch on the safelights.
 Start clock immediately.
 Wait for 30 seconds.
 Move second sheet of card down 3cm (the first sheet of card must remain in place throughout).
 Wait 30 seconds.
 Repeat the process every 30 seconds until the bottom of the film is reached.
 Switch off the safelights immediately.
 Process the film.

Method 2
 Place cassette face up on the x – ray table.
 Set a FFD of 100cm.
 Cover one third of the cassette with lead rubber, lengthways (area C).
 Collimate to the uncovered area of the cassette.
 Expose the film using a minimum exposure (suggested exposure 45Kv 2mAs).

86 | P a g e
  Unload the cassette in the darkroom in total darkness.
 Place the film on the workbench.
 Cover one third of the exposed side of the film with the sheet of cards, lengthways (area A).
 Cover half of the film horizontally, leaving the bottom half uncovered.
 Switch on the safelights.
 Start clock immediately.
 Wait for 30 seconds.
 Switch off the safelights immediately.
 Process the film.

Lloyd P. J (2001), pp 79-80

Appendix 12
Reject film analysis

Table 1

21/06- 28/06- 05/07- 12/07- 19/07- 26/07- 02/08- 09/08- Total

25/06 02/07 09/07 16/07 23/07 30/07 06/08 13/08

Positioning Error

87 | P a g e
 Movement

Underexposed

Overexposed

Fogging

Equipment Error

Processing

Double Exposure

Lloyd P. J (2001), pp 140

Appendix 13
Reject Film Analysis

Table 2

Monday Tuesday Wednesday Thursday Friday Total

31/05-
04/06

88 | P a g e
 07/06-
11/06

14/06-
18/06

21/06-
25/06

28/06-
02/07

05/07-
09/07

12/07-
16/07

19/07-
23/07

Total Films Rejected -

89 | P a g e