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M4: Radiology > Radiology 8 > Flashcards

Radiology 8 Flashcards

1
Q

What is quality assurance?

A

WHO definition: “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

Ways in which human error can be reduced

A
  • Introduce simple systems (SOP)
  • Improve working environment
  • Encourage reporting - without blame
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3
Q

SOP

A

Standard operating procedures

  • written guidelines on how to perform a task to make sure everyone does it the same way every time.
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4
Q

How might the working environment be improved?

A

Ergonomics of the department.
Organise the equipment that will be needed for the tasks.
Is the darkroom too hot/small/light/dark etc?

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5
Q

What is the legislation surrounding QA?

A

IR(ME)R: The ionising radiation (medical exposure) regulation 2017 to protect the patient.

IRR: The ionising radiation regulation 2017 protect both staff and public but also deal with patient protection in relation to the equipment we use.

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6
Q

IRMER 2017 - clearly defined roles: employer

A

Employer - the boss, must ensure that their establishment is complying with IRMER.

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7
Q

IRMER 2017 - clearly defined roles: practitioner

A

The person who justifies the exposure. They must be aware of and adhere to the correct referral criteria for dental exposures. The practitioner assumes legal responsibility for the exposure when they put their name to it.

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8
Q

IRMER 2017 - clearly defined roles: operator

A

Anyone who is involved in the production of a radiograph. That includes the person who asks the patient to simply sit in the chair, to the nurse who develops the film.

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9
Q

IRMER 2017 - clearly defined roles: the referrer

A

The person who has clinically examined the patient and referred them for the radiographs and who is responsible for viewing that radiograph and recording the findings in the patient’s notes.

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10
Q

IRMER 2017 - clearly defined roles: dentist

A

Dentists are quite unique in the fact that they can be every single one of these roles, therefore need to pay close attention to this document.

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11
Q

What are the two specific regulations within IRMER?

A
  1. Employer shall establish QA programmes for standard operating procedures.
  2. Employer shall ensure that every practitioner and operator undertakes CPD.
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12
Q

What is the training requirements for a dentist in terms of IRMER?

A

Every practitioner and operator involved in dental radiography must be able to prove that they have undergone 5 hours of CPD specific to radiation safety every 5 years. It is not enough just to qualify and forget about IRMER, it is your responsibility to keep up to date with procedures and legislation on a regular basis. That means attending refresher courses and keeping evidence to prove you have done it.

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13
Q

The basic SOPs

A
  1. How we justify the exposure
  2. How we correctly identify the patient
  3. How we collect the equipment
  4. How we expose the patient
  5. How we clean the phosphor plates and develop them.
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14
Q

Where should you look to for more information on how to set up QA programme?

A

Guidance Notes for Dental Practitioners on the Safe use of X-ray Equipment, 2nd Edition by Public Health England.

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15
Q

First step in setting up your QA programme

A

Name a person who will be in charge of overseeing compliance (this would normally be your Radiation Protection Supervisor or RPS).

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16
Q

QA programme summary

A
  1. Details of procedures carried out
  2. Frequency procedures carried out
  3. Frequency records will be audited
  4. All the above must be put in writing
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17
Q

So what exactly do we look at in QA programme?

A

Image quality
X-ray equipment
Image processing (film and digital)
Working procedures
Training
Audit

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18
Q

How do we ensure high quality images?

A
  • Image quality rating system
  • Film reject analysis
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19
Q

Image quality rating system

A

Images are rated either 1,2, or 3.

Collate the results: analyse monthly, quarterly or at least every six months.

Feed back results to staff (audit tool can also be used for CPD).

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20
Q

Image quality rating?

A

1 - Excellent: No errors of patient preparation, exposure, positioning, processing or film handling.

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21
Q

Image rating quality?

A

2 - 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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22
Q

Image quality rating?

A

3 - Unacceptable: errors of patient preparation, exposure, positioning, processing and/or handling which render the radiograph diagnostically unacceptable.

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23
Q

Targets for films rated 1,2,3

A

1 >70%
2 <20%
3 <10%

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24
Q

Film reject analysis

A
  1. Collect all rated 3 films
  2. Assess these films at the end of each month
  3. Categorise faults (e.g. exposure, positioning, processing etc.)
  4. ACT
  5. Repeat monthly and compare results/trends.
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25
Q

IQRS audit cycle

A
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26
Q
A

Not Acceptable - positioning fault, overlapped teeth

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27
Q
A

Acceptable

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28
Q
A

Not acceptable - collimation fault, bone level cut off.

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29
Q
A

Not acceptable - positioning fault, missed tooth in question

30
Q
A

Acceptable - if patient has no 8s, not acceptable if patient has 8s.

31
Q
A

Not acceptable - collimation and exposure fault

32
Q
A

Acceptable - evidence of collimation but image diagnostically acceptable.

33
Q
A

Not acceptable - positioning and collimation faults, elongation.

34
Q
A

Acceptable

35
Q
A

Acceptable - if taken for LL2, not acceptable - if taken for LL3

36
Q
A

Acceptable

37
Q

X-ray equipment requirements

A
  1. Inventory must be kept.
  2. Regular testing (every 3 yrs or so)
    - this includes checking representative patient doses.

*at DDH we QA test our equipment every 3 months.

38
Q

What happens to the equipment annually?

A

Annual service by a suitably qualified engineer (company called MI Healthcare).

39
Q

What information can you find out from the box of film?

A

Size of the film
Liability notice
Best before date
Storage instructions

40
Q

Storage recommendations for film

A

Keep out of direct sunlight, away from radiation source and at optimum humidity and temperature.

41
Q

How should digital be stored?

A
  • Should be kept cool
  • Not too humid an environment.
  • Out of direct sunlight
  • Away from UV radiation
  • In light protective/cross infection barrier envelopes
  • If the plate or sensor has not been used for more than 24 hours it should be erased again before use
42
Q

What is the main method of checking performance known as?

A

Sensitometry

43
Q

What does sensitometry involve?

A

A daily check of the developer, the idea 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.

44
Q

What image can you expect to see if the developer has become exhausted?

A

Will give you a pale image.

45
Q

How is the developer checked?

A

Place a step wedge on a film and expose using a set exposure every day. A step wedge is a tool or phantom made up of differing layers of metal. When it os radiographed it will produce an image showing steps of blackening from pale grey to dark grey/black. The step wedge is place on a film and exposed. This film is then processed in fresh chemistry and becomes your standard reference film. Expose the step wedge daily using the same exposure factors and process the film. Compare with the reference film and check for any obvious change in densities.

46
Q

What is this?

A

This is an example of a manufactured step wedge.

47
Q

What is this?

A

A DIY step wedge made from the foil from inside discarded film packets which have been layered up.

48
Q

What results would you expect to see when assessing the developer if it needs to be changed?

A

…and this is what you should be looking out for. You can see there has been a one step change in the density between the 2 films. The darkest square on the right hand film is now comparable with the middle square on the reference film. The developer is now exhausted and should be changed.

49
Q

How do you alleviate the subjectivity and keep consistency of assessing the developer quality?

A

How one person views a film can be quite different from another. For consistency, the same person should carry out the testing over one cycle of the developer.

50
Q

What is this?

A

A ready exposed sensitometry test film which allows you to miss out the step of exposing the step wedge.

The film comes in a light tight bag which you unwrap in darkroom conditions or inside a glove box and process.

Once developed you should write the date on the top of the film for reference, then you simply pop it in to the reader and you are given an answer. If green is illuminated the developer is good, amber it is OK but not optimal. Red your developer is exhausted.

51
Q

Pros/cons of the step wedge system

A

The step wedge system is cheap and uses intra-oral film you already have, it requires no extra film or kit. However, operator variables can cause discrepancies in production and results can be variable depending on the viewer.

52
Q

Pros/cons of the pre-exposed film

A

The pre-exposed film is expensive to buy but it is very easy to use. There will be no discrepancies in production, every film will be the same and the results are not viewer dependant.

53
Q

Common problems when processing film

A
  1. Damage can be caused by poor handling of the film, bends or crimp marks caused by either teeth or nails.
  2. Films may become overlapped moving through the processor and has the operator been adequately trained to use the processor.
  3. There are also several stages that the film could have been exposed to light resulting in fogging on the film.
54
Q

What has happened to this film?

A

This is the typical appearance of a fogged film. Part of the film has been drastically overexposed due to unintentional contact with light.

55
Q

What are the typical causes of fogging of film?

A
  1. The usual causes of fogged film are that light may be leaking into the darkroom or daylight loading system.
  2. Has a box of film been opened and not stored properly – not in the hopper or with lid off the box? 3. Is the safelight correct?
  3. Is the filter the correct colour for the film type being used or is it simply too close to the worksurface?
  4. The safelight should be a minimum of 1.5m away from the worksurface.
56
Q

How can you check your darkroom conditions?

A

Coin test

57
Q

The coin test

A

*Image shows an example of what you don’t want to see on your test film.

  1. To perform a coin test open an intra-oral x-ray packet and remove the film while your hands are inside the glove box or in the darkroom under a safelight.
  2. 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.
  3. Remove the coin and process the film, then check for any light fogging on the processed film.
  4. The test should be repeated for every type of film used in the department or practice. If the film is greatly fogged you must change your safelight or check for light leakage around your glove box.
58
Q

How often should you perform a visual check on solid state sensors and PSP plates?

A

Weekly: for any signs of damage, and x-ray the sensor once a month and study the resultant image.

59
Q

How often should you perform a visual check on PSP plates?

A

weekly

60
Q

For extra-oral cassettes and large digital sensors you should purchase a test tool which is a piece of plastic which you set on the cassette or sensor and x-ray it. When the image is developed, what will you expect to see?

A

For extra-oral cassettes and large digital sensors you should purchase a test tool which is a piece of plastic which you set on the cassette or sensor and x-ray it. When the image is developed this is what you will see. You then record how many different coloured squares you can see which measure contrast and brightness, and the number of boxes displaying distinguishable line pairs which checks the resolution. Any discrepancies from month to month should be acted upon.

61
Q

What can be seen here?

A

examples of solid state sensors with damage probably caused by dropping, but remember patients can also cause damage with their teeth.

62
Q

What can we see here?

A

These images are damaged phosphor plates:
1. The first plate is badly scratched either from poor handling, processor wear and tear or cracking of the phosphor coating.
2. The second plate has either been exposed to direct sunlight or extreme temperature and the last one has been caused by a spec of dust on the laser reading the plate in the processor.
3. The plate might be OK and should be checked for any scratches but the processor will need to be cleaned.

63
Q

What’s happened here?

A

Bend

64
Q

What’s happened here?

A

thumb print

65
Q

What’s happened here?

A

Scratch/crack

66
Q

What’s happened here?

A

Bite

67
Q

What are local rules?

A

As part of IRMER 17, employers must have defined “local rule”.

  1. You should define which types of x-ray procedures are to be carried out within your designated controlled area.
  2. Who has access to and is responsible for safety in each controlled area.
  3. You should have a SOP for correctly identifying your patient and whose responsibility it is to check.
68
Q

Working procedures: what should be included in the standard operating procedures (SOPs)?

A

Anything that indirectly affects radiation safety or the diagnostic quality of your radiographs. For example, the correct preparation and use of processing chemicals and the handling of the phosphor plates.

69
Q

Two categories of staff when taking radiographs?

A
  1. Those taking the radiograph
  2. Those assisting taking the radiograph
70
Q

Training of anyone taking a radiograph

A

Must be qualified e.g. a state registered dentist, hygienist with a certificate in dental radiography, dental nurses with a post-qualification certificate in dental radiography or radiographers. Must also be able to provide evidence that they are competent to use the equipment in the practice.

  • Training records of everyone involved must be comprehensive.
71
Q

Audits

A
  • Employ services of a specialist external radiation protection advisor or RPA, such as public health England who will help and advise if you are IRMER compliant.

M4: Radiology (16 decks)

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