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M4 Radiology > Quality Assurance > Flashcards

Quality Assurance Flashcards

1
Q

Define quality assurance

A

An organised effort by staff to ensure that the diagnostic images produced are of sufficiently high quality to consistently provide adequate diagnostic information at the lowest possible cost and the least possible exposure to the patient.

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2
Q

Why must we QA?

A

Due to:

  • Human error
  • Legislation
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3
Q

What are 3 ways of reducing human error?

A

Human error can be reduced by:

  1. Introducing simple systems, SOP
  2. Improving working environment
  3. Encouraging reporting without blame
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4
Q

What are SOPs?

A

Written guidelines on how to perform a task to make sure everyone does it the same way every time.

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5
Q

Why does legislation exist?

A

To ensure all establishments who expose people to radiation are taking responsibility for their actions. Radiation is dangerous.

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6
Q

What set of regulations protect the patient?

A

The Ionising Radiation (Medical Exposure) regulations (IR(ME)R 2017)

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7
Q

What set of regulations protect both staff and the public,

and also protect the patient in relation to equipment use?

A

The Ionising Radiation Regulations 2017 (IRR 2017)

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8
Q

There are specific roles in IRMER 17.

What is the Employer’s (boss) role in IRMER 17?

A

They must ensure their establishment is complying with IRMER7

  • Compliance must be faultless as you can be inspected by the HSE.
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9
Q

What is the practitioner’s (person who justifies exposure) role in IRMER 17?

A
  • Must be aware of and adhere to the correct referral criteria for dental exposures
  • Assumes legal responsibility for the exposure when they put their name to it.
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10
Q

What is the referrer’s (one who refers the patient for radiographs) role in IRMER 17?

A

Responsible for viewing that radiograph and recording findings in the patients notes

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11
Q

What are the two specific regulations in IRMER?

A
  1. The employer shall establish QA programmes for standard operating procedures.
  2. The employer must ensure every practitioner and operator undertakes CPD:
    - 5 hours of CPD specific to radiation safety every 5 yrs
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12
Q

What do SOPs involve in an X-ray department?

A
  • How we justify the exposure
  • To how we correctly identify the patient
  • To how we collect equipment
  • Expose the patient
  • To how we clean the phosphor plates and develop them
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13
Q

How is QA carried out?

A
  • Named person in charge of overseeing compliance
  • Details of procedures involved
  • Frequency procedures carried out
  • Frequency records will be audited
  • All the above must be put in writing
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14
Q

What do we look at in a Q.A programme?

A
  • Image quality
  • X-ray equipment
  • Processing (film and digital)
  • Working procedures
  • Training
  • Audit
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15
Q

How are high quality images ensured?

A

By auditing the images that are produced by using;

1) Image Quality Rating System on every image we take
(2) Film Reject Analysis

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16
Q

How should images be rated?

A

Either diagnostically acceptable (A) or diagnostically not acceptable (N)

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17
Q

Outline the steps of image quality rating system:

A
  1. Asses all images produced.
  2. Grade films by image quality
  3. Images are rated either 1, 2 or 3
  4. Collate Results - analyse monthly, quarterly or at least every six months.
  5. Feed-back results to staff.
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18
Q

What are the characteristics of an image quality rating 1?

A

Excellent – No errors of patient preparation, exposure, positioning, processing or film handling

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19
Q

What are the characteristics of an image quality rating 2?

A

Diagnostically acceptable – some errors in patient preparation, exposure, positioning, processing or handling which do not detract from the diagnostic utility of the radiograph

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20
Q

What are the characteristics of an image quality rating 3?

A

Unacceptable – Errors of patient preparation, exposure, positioning, image processing or reconstruction which render the radiograph diagnostically unacceptable. The image must be repeated.

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21
Q

As a health professional what % of A rated radiographs should you aim for?

A

> 95% for digital

90% for film

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22
Q

What is film reject analysis?

A

Film reject analysis is a component of QA.

It involves recording the reason you rejected the image

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23
Q

Why is film reject analysis important?

A

Because it is possible to spot trends.

Spotting trends will allow you to take appropriate action to try and minimise or eliminate errors.

It might indicate if an individual needs more training or support or if its something specific to equipment that hasn’t been picked up by QA test

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24
Q

What are the 5 steps of film reject analysis ?

A
  1. Collect all 3 rated films
  2. At end of each month assess these films
  3. Categorise faults e.g Exposure, Positioning, Processing etc
  4. ACT
  5. Repeat every month and compare results
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25
Q

Why should all N rated films be kept?

A

So they can be analysed.

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26
Q

If using a digital system, what should be recorded?

A

The date, time, nature of the deficiency and number of repeat radiographs must be recorded.

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27
Q

When is it recommended that reject analysis should be performed?

A

Aat the same time as image quality analysis.

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28
Q

How often should film reject analysis be carried out?

A

Preferably monthly, but at least every 6 months.

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29
Q

What is the IQRS audit cycle?

A

A continuous cycle

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30
Q

What are the 4 stages of the IQRS cycle?

A
  1. Asses - evaluate image
  2. Grade - 1, 2 or 3
  3. Results - analyse and look for ways to improve
  4. Feed-back to staff

REPEAT

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31
Q

How often should equipment be tested to check it is working satisfactorily?

A

Preferably annually but minimally every 3 years.

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32
Q

What should equipment checks involve?

A
  1. Representative patient doses

2. Annual routine maintenance

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33
Q

How are representative patient doses measured?

A

This is done by carrying out a series of exposures over a dosemeter which tells you the exact measurement of equivalent dose.

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34
Q

At DDH how often are equipment tests carried out?

A

Every 3 months

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35
Q

At DDH how often are medical physics tests carried out?

A

Every 3 years

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36
Q

What are important things to consider when processing film?

A
  1. Make sure newly stocked boxes aren’t used first
  2. Processor performance must be monitored and maintained
  3. Performance of digital system must be monitored.
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37
Q

Why should you be careful not to over order?

A

As films start to degrade as they age. You must not over order in case films aren’t used in time before the best before date

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38
Q

What are the best conditions for film storage?

A

Storage instructions are found inside box. Keep your stock;

  • Out of sunlight
  • Away from radiation
  • At optimum humidity and temp.
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39
Q

What are the best conditions for digital - PSP storage?

A
  • Cool and not too humid
  • Avoid direct sunlight and UV
  • Preferably in light protection/ cross infection barrier envelope.
  • If not used for more than 24hrs after plate erased (exposure to bright light) it should be erased again.
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40
Q

What is the main method of testing performance?

A

Sensitometry

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41
Q

What does sensitometry involve?

A

A daily check of the developer. The idea of this is to compare a film developed with fresh chemistry with a new film taken every day to check image quality has not deteriorated as the developer becomes exhausted.

42
Q

What happens to the image as a result of an exhausted developer?

A

Exhausted developer will give you a pale image.

43
Q

How is sensitometry carried out?

A

Place a step wedge on a film and expose using a set exposure every day.

44
Q

What is a step wedge?

A

A step wedge is a tool or phantom made up of differing layers of metal.

When it is radiographed it will produce an image showing steps of blackening from pale grey to dark grey/black.

45
Q

How do you make a DIY step wedge?

A

Layer up foils from inside discarded film packets

46
Q

What are the 4 steps followed when using a step wedge during sensitometry?

A
  1. The step wedge is placed on a film and exposed
  2. This film is then processed in fresh chemistry and becomes your standard reference film.
  3. Expose the step wedge daily using the same exposure factors and process the film.
  4. Compare with the reference film and check for any obvious change in densities.
47
Q

Why should the same person carry out the testing over one cycle of the developer?

A

For consistency - How one person views a film can be quite different from another.

48
Q

Once the film is developed, what should you do immediately?

A

You should write the date on the top of the film for reference then pop it in to the reader and you are given an answer.

49
Q

When developing what does the red, amber and green colours indicate?

A

Red - developer is exhausted.
Amber - OK
Green - developer is good

50
Q

What are the advantages of the step wedge system?

A
  1. It is cheap
  2. It uses intra-oral film that you already have
  3. It requires no extra film or kit
51
Q

What are the disadvantages of the step wedge system?

A
  1. Operator variables can cause discrepancies in production

2. Results can be variable depending on the viewer

52
Q

What are the advantages of pre-exposed film?

A
  1. Is very easy to use
  2. There will be no discrepancies in production
  3. Every film will be the same and the results are not viewer dependant.
53
Q

What are the disadvantages of pre-exposed film?

A

Is expensive

54
Q

What are some common problems that arise when processing films?

A
  1. Damage can be caused by poor handling of the film
  2. Bends or crimp marks caused by either teeth or nails.
  3. Films may become overlapped moving through the processor
  4. There are also several stages that the film could have been exposed to light resulting in fogging on the film.
55
Q

What are the usual causes of fogged film?

A
  1. Light may be leaking into the darkroom or daylight loading system.
  2. Box of film been opened and not stored properly
  3. Incorrect safelight
  4. Filter incorrect colour for film type
  5. Safelight too close to work surface
56
Q

What test checks your darkroom conditions?

A

Coin test

57
Q

What are the 6 steps of a coin test?

A
  1. Open an intra-oral x-ray packet
  2. Remove the film while your hands are inside the glove box or in the darkroom under a safelight.
  3. Place a coin on the film and leave for a specified length of time, usually the average working time you would require to perform darkroom tasks.
  4. Remove the coin and process the film
  5. Check for any light fogging on the processed film.
  6. The test should be repeated for every type of film used in the department or practice.
58
Q

What do you do if the film is greatly fogged?

A

You must change your safelight or check for light leakage around your glove box.

59
Q

Why should computer monitors be checked?

A

To make sure they remain on optimum settings.

60
Q

If using solid state sensors, what should you do to check for any signs of damage?

A
  1. Perform a weekly visual check

2. X-ray the sensor once a month and study the resultant image

61
Q

What should happen to PSP plates when they start to show any sign of damage?

A

They should be discarded and replaced with new ones.

Consequently, you should always have spare ones in stock.

62
Q

For extra-oral cassettes and large digital sensors, what should you purchase

A

A test too - a piece of plastic which you set on the cassette or sensor and x-ray it.

63
Q

List the most common appearances you might see when you do your monthly plate QA?

A
  1. A bend in the plate
  2. A thumb print
  3. A scratch or crack in the phosphor layer
  4. A bite or tooth mark.
64
Q

Your staff will fall into 2 categories. What are these 2 categories?

A
  1. Those taking radiographs

2. Those assisting in the process

65
Q

Why must your procedures be robust and backed up by evidence?

A

As each procedure in a QA programme is subject to audit

66
Q

Why must all SOPs should have regular review dates?

A

To ensure they are relevant and fit for purpose.

67
Q

Is film used with digital systems?

A

No

68
Q

What are the potential causes of a weak or pale image?

A
  1. Incorrect exposure factors - not enough radiation equals an underexposed image.
  2. Film not left long enough in the developer tank
  3. Developer exhausted
  4. Developer at too low a temperature
  5. Incorrectly diluted chemicals
69
Q

What can we observe when there is incorrect exposure factor selection on a phosphor plate and what does this mean?

A

Speckled white areas appear on radiograph - this suggests these areas have had no exposure to radiation so the phosphor crystals cannot emit light.

Consequently there is no information for the computer software to convert into a shade of grey from those particular pixels

70
Q

What size of film should always be used for anterior teeth?

A

Size 0

71
Q

What does collimation mean?

A

Restricting and confining the x-ray beam to a given area

72
Q

If using film, what procedures should further be carried out?

and most importantly what must you get correct?

A

Sensitometry testing and log routine processor maintenance.

Most importantly always select the correct exposure factors and regularly check your x-ray tube output.

73
Q

What does an area of fogging suggest?

A
  1. That the film has either been exposed to light leakage before it has been exposed through incorrect storage

or

  1. It has been handled wrong during processing, possibly from light leaking into the glove box of the processor.
74
Q

What can happen to the outcome of the radiograph if the vertical angulation of the tube or film is wrong?

A
  • Teeth appear elongated

- Missing apices

75
Q

What might a blurred image suggest?

A

Patient movement during exposure.

76
Q

What type of regular test and conditions will help prevent fogging?

A

Carrying out the coin test regularly in glove boxes and under the safelight

77
Q

What are the potential causes of a dark image when using film?

A
  1. Incorrect exposure factors:
    - too high exposure will give a dark image
  2. Processing fault:
  • film spent too long in developing tank
  • developer temp too high
    developer not diluted enough when it was changed
78
Q

How can processing faults be prevented?

A
  1. By routine maintenance of the processor

2. By regular checking of the developer temperature.

79
Q

How can processing faults be reduced?

A

By having a robust QA programme including regular staff training

80
Q

What is the cause of a green/yellow tinted film?

A

Insufficient fixing during processing.

81
Q

What appears on the radiograph if chemicals are not properly washed from the film during processing?

A

Patterns

82
Q

Splash marks can be seen on radiographs as dark and clear spots.

  1. What are the dark spots caused by?
  2. What are the clear spots caused by?
A
  1. Dark spots - caused by developer splashes

2. Clear spots - caused by fixer splashes

83
Q

How can splash marks be prevented?

A

Processor maintenance is the key to preventing this and making sure your water is regularly changed.

84
Q

What causes a lightning strike/tree pattern on a radiograph?

A

Static electricity discharging on the film.

It can be caused when a film is pulled quickly from the packet when the atmosphere is dry.

85
Q

How can this lightning strike/tree pattern be prevented?

A

By making sure your darkroom is well ventilated and your film is stored correctly.

86
Q

How can faults with scanners or processing towers be prevented?

A
  1. By careful handling of digital equipment.
  2. Any scanners or processing towers should be regularly maintained by service engineers
  3. Phosphor plates and sensors should be scanned monthly and checked for damage.
87
Q

How often should your plates be imaged to check for wear and tear?

A

Monthly

88
Q

Why is a back to front film packet not acceptable?

A

As the image produced will have visible foil marks and the lead foil will partially absorb the X-ray photons giving an under exposed image.

89
Q

What are crimp marks?

Are crimp marks acceptable?

A

Nail marks and scratches on the film emulsion due to poor handling.

They are NOT acceptable

90
Q

Is using the wrong side of the receptor acceptable?

A

No

91
Q

How would a bend in the corner of a film affect the image?

Is a film corner bend acceptable?

A

Cusps would appear separated and teeth slightly elongated.

This is just acceptable

92
Q

Are missing bone levels due to collimation acceptable?

A

No.

93
Q

Can you use a film twice (double exposed)?

A

No

94
Q

What can be seen when the tongue isn’t pressed up against the palate?

A

Central air shadow

95
Q

What can be seen if jewellery eg. earrings, aren’t removed?

A

Ghosting

96
Q

What happens when patient is too far into the machine?

A

Narrow incisors - this is not acceptable.

97
Q

Metal strip in nosebar causing artefact - is this acceptable?

A

Acceptable as there’s no detriment to image

98
Q

What is observed when the phosphor plate is completely bent in half?

is this acceptable?

A

A mirror image double exposure.

This is not acceptable!

99
Q

What can be observed if mandible is too far out of machine and not in the focal trough?

A

Broad unsharp incisors

100
Q

Blood splatter on phosphor plate which had leaked inside the barrier bag which had not been properly sealed.

Is this acceptable?

A

No.

M4 Radiology (12 decks)

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