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


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

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


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

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


According to Stewart (1993), essentially, three steps are involved in a
quality control program. There are;
i. Acceptance Testing: These are test conducted on every new x-ray
facilities e.g. the x-ray machine, cassettes, intensifying screens,
grids, to name but a few. This test is carried out prior to it clinical
usage to show if the equipment is performing within the
manufacturer’s specification. This test must be done by someone
other than the manufacturer or his representative.
ii. Routine Performance Evaluation: With use, these x-ray
equipments deteriorate. This necessitates the periodic quality
control evaluation of these equipments. That is, these are the
quality control tests conducted on these equipments to see if the
equipment will meet predestined requirements.
iii. Error Corrections: When these equipment performances are not
optimal or do not meet predetermined requirements, or errors found
after the quality control test has been conducted, actions are taken
to effect corrections on them.
5.1 General Consideration:
An adequate quality control program for any individual facility will
depend on a number of factors which include, but may not necessarily be
limited to, items such as the type of procedures performed, type of
equipment utilized, and patient workload. This program is developed under
the guidance and supervision of a medical physicist qualified in this area of
expertise by education, training, and experience.

5.2 Equipment Log:

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

5.3 Recording Test Data:

All quality control test data should be recorded on standardized forms. It
is suggested by AAPM (1981), that each institution develops its own forms
suitable to its own needs.
1. The use of standardized forms will assure that all of the required data
will be obtained.
2. Forms should be filed as part of the room log.
3. The charting of trend data is a recommended procedure which will
allow easy identifications of variation with time. This is of particular
value in the case of film processors.

5.4 Conditions of the X-Ray Equipment:

5.4.1 Mechanical Integrity: As noted in ICRU Report 54 (1996), a general
observation of the diagnostic system should be made. Key items to
look for are the presence of loose or absent screws, bolts, or other
structural elements that may have been improperly installed or have
worked loose due to use. The functioning and operation of meters,
dials, and other indicators like the pilot lights should be checked.
5.4.2 Mechanical Stability: To obtain a diagnostic quality radiograph, it is
important to minimize patient motion. The availability and adequacy of
patient support devices such as the table or immobilizing devices
should also be checked. ICRP Pub. 60 (1991) added that, it is equally
important to check the reproducibility of positioning of the source and
image receptor that may be indicated or controlled by physical marks
or detents. A check of the accuracy of angulations scale should also be
5.4.3 Electrical Integrity: The external condition of the high voltage cables
should also be observed. Check to make sure that the retaining rings at
the termination points are tight and that there are no breaks in the
insulation. (ICRU Report 54, 1996). It is important to observe the "lay"
of the cables, how they are being hanged, so that they don’t interfere
with tube positioning.
5.4.4 Alignment and SID: Source to image receptor distance (SID)
indicators should be checked. The consistency between multiple SID
indicators (indicators on the tube support and the collimator) should be
verified. The accuracy of these indicators should also be verified with a
tape measure. Verification of proper grid installation should be made.
This check should also include a verification of the alignment of the x-
ray source and the center of the grid.
5.5 The Radiograph As A Quality Control Tool:
Patient’s radiographs are also considered one of the quality control
tools of which they are being checked on periodic basis and should be
factored into any departmental evaluation program.
5.5.1 Rejected Films Analysis: Rogers (2008) defined Film Reject as “a
film deemed useless and discarded with another film being taken” and
A Repeat Film as “a film retaken to provide extra/missing diagnostic
information sent with the original for reporting”.
Film Reject Analysis according to Suleiman and Showalter (1984)
are periodic assessment and checks on rejected films as well as the
accepted ones usually on monthly intervals so as to identify the
problem, determine it cause and find solutions to it, all aiming at
reduction of film reject rate.
The causes of rejection of films are analyzed according to the
– Too dark, too light (under/over exposure)
– Positioning/Collimation errors
– Patient movement
– Processing errors
– Others
Reference data should also be assigned to this analysis e.g. date/time,
operator ID code, room, exam type, reject or repeat, etc.
5.5.2 Accepted Films Analysis: Good practice should always question the
adequacy of radiographs of less than optimal quality for their
acceptability in making a diagnosis. Repeating a procedure to get a
film of optimal quality is often not necessary and should be evaluated
in terms of the radiation exposure and cost of the retake. Since one
should expect to find films of less than optimal quality in a
departmental file, an analytic review of these films should be made on
a regular basis.

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

6.1 Screen/Film Combination:

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

levels to be produce; etc must be put into consideration. (Gray and Winkler,

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

To achieve a consistent exposure level, an automatic exposure control

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

6.3 Scattered Radiation And Use Of Low Attenuation Components:

Scattered radiations are produced when x-rays are attenuated at
angles different from the incident rays by the body tissue. These scatter is
increased with increase thickness of body part examined, e.g. skull, pelvis,
lumbar spine examinations.

As noted in IAEA Publication (1995), radiation scatter has adverse
effects on our radiographs which are;
i. Decreases the light transmitting ability of our film.
ii. Decreases slightly the sharpness of the recorded detail.
iii. Increases the random background noise of the film and all these
will result in
iv. a reduction in the contrast of the film.
The amount of scattered radiation can be reduced by means of an anti-
grid. (Bauer, 1998). The grid consist of a plate containing thin strips of lead
lying perpendicular to the plated surface, which are sandwiched between a
low attenuation inter-space material which are radiolucent materials made of
either aluminium or polyester. X-ray photons are more likely to be attenuated
by the lead strips. (Sandborg and Carisson, 1993).
Secondary radiation grids are not used for examination of the body
parts but only parts intended to produce scatter maybe as s result of
increase in the tube potential difference (kVp).

6.4 Beam Collimator and X-Ray Projection:

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

6.3 Film Processing:
The final stage in the production of a radiograph is processing the film.
If processing conditions are not optimal, the film will require a higher
radiation dose in order to provide an acceptable film density. Chemicals
should be changed regularly, and the processing conditions, such as
temperature and development time should be carefully optimized. A system
of quality control that involves checking temperatures of processing
chemicals and carrying out sensitometry, involving development of a test
strip of film exposed to a range of light levels ensures optimal performance.
(BIR Pub. 2001). These checks should be carried out daily to monitor
performance in terms of film density, contrast and background fog level. The
performance levels of processors that have a relatively low workload need to
be monitored carefully.
Gray and Winkler (1983) noted that, film processing affects the film
density; therefore, it influences the speed index. Thus, the measurements of
the characteristic curve for a film will also reveal problems with processing. If
a film is taken with optimized processing, it can be considered the reference
standard. Checks can then be made by comparing future results with the
reference standard to identify any deterioration.


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

7.1 Processor Quality Control (Sensitometry):

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

7.2 System Constancy Test:

Objective: To assure that the radiographic system is operating consistently.
Suggested Performance Criteria: Optical density on test film within 1
step of comparison film.
Frequency: This test should be carried out monthly and after service of the
Required Equipment: Include; Aluminum step wedge, quality control
cassette, film, densitometer
1. Set the x-ray unit to the technique factors and source-to-image distance
2. Place the step wedge on the loaded QC cassette on the table top and
center the x-ray beam to the step wedge.
3. Collimate to the edges of the step wedge.
4. Make an exposure of the step wedge and process normally.
5. Using the densitometer, compare the optical densities for Steps 4 through
8 with the comparison film.
6. Record your results on the monthly quality control checklist.
Evaluation: Compare the current film with the comparison film. If the
densities are not within 1 step of the comparison film, constancy has not
been maintained and clinical images should not be taken until the problem
has been identified and corrected.
Corrective Action: Repeat the test to confirm results. Verify that the
processor is in control. Contact your x-ray and processor service engineers.

7.3 Daily And Weekly Darkroom Quality Control

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

7.4 Radiographic Illuminators Quality Control:

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

7.5 Visual Checklist:

Objective: To assure that all components of the radiographic x-ray system
indicator lights, displays, and mechanical locks and detents are working
properly and that the mechanical rigidity and stability of the equipment is
Suggested Performance Criteria: Each of the items listed in the QC Visual
Checklist should pass or receive a check mark. Items not passing the visual
check should be replaced or corrected as soon as possible.
1. Quarterly
2. After service or maintenance on the x-ray system.
1. Collimator light brightness and cleanliness.
Determine if light is functioning and is clearly defined under normal
operating conditions, without visible dust or foreign matter shadows.
2. Collimator beam limiting devices (BLDs) available and used.
If unit provides variable collimation, determine that they are
functioning correctly and smoothly. If manual beam limiting devices are
being used, assure they are sufficient for confining the x-ray beam to
the area of clinical interest. Assure that both types are being used
3. Locks and detents operable.
Check to make sure all locks and detents are functioning as intended.
Assure that the x-ray tube maintains its position at the clinically used
4. Boom smoothness of motion.
Determine if boom moves easily without catches or interruptions.
5. Grid condition and operation.
If grids are being used, check that grid lines, grid cutoff, or grid
damage is not visible on films. Assure that grid is properly positioned,
centered to central ray and if a focused grid is being utilized that the
correct focal distance if being used.
6. Condition of cables.
Inspect all cables for frayed coverings, kinks, and determine that
cables are free from friction from other objects.
7. Tube or generator oil leakage.
Visually inspect areas around x-ray tube and generator for oil or
abnormal collection of dust attaching to oil leaks.
8. Cassettes and screens condition.
Cassettes and screens should be cleaned regularly. Check screen
condition for dust particles, scratches, and areas of discoloration.
Assure screens are properly fitted and attached to cassettes. Check
cassette latches to make sure they are functioning properly and are
not broken. Cassettes and screens should be replaced if necessary.

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

7.6 Repeat Analysis:

Objective: To identify ways to minimize patient exposure and reduce costs
by addressing higher than normal repeat rates.
Suggested Performance Criteria: The criteria associated with repeating a
film is subjective. There is no good way to determine what the repeat rate
should be. Each facility should decide on its own, but should strive for a
repeat rate of no greater than 5 to 7%.
1. Ongoing tracking of films
2. Quarterly data analysis

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

7.7 Film and Chemical Storage:

Objective: To assure film and chemistry quality is maintained and inventory
is rotated on a first in, first out basis.
Frequency: Quarterly
1. Maintain inventory so first in is first out.
2. Maintain the temperature and humidity to manufacturer

3. Follow the chemistry manufacturer guidelines for replacement and
4. Record results on the Quarterly QC Checklist.
Corrective Action: If storage conditions exceed manufacturer’s
recommendations, take the necessary steps to resolve the problem.

7.8 Artifact Evaluation:

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

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

7.10 Darkroom Integrity or Fog Test:
Objective: To determine and minimize the amount of darkroom fog.
Suggested Performance Criteria: An optical density increase of 0.05 or
1. Semiannually, with each type of film used clinically
2. After bulb or filter replacement
3. After changing or adding types of film
Required Equipment: Includes; opaque material (manila folder), watch or
timer, attenuation block (aluminum step wedge, phantom, acrylic block) to
create a medium, optical density of about 1.0 on the film, densitometer.
1. Load a cassette with film and place on a flat surface.
2. Center the attenuation block and expose the film using an x-ray
technique that will result in an optical density of about 1.0 after the
film is processed.
3. With the safelights on, place the exposed film on the work area in the
darkroom. Cover half the film with opaque material, bisecting the
latent image parallel to the long axis of the film.
4. Leave exposed film on the counter for 2 minutes, then process as
5. While waiting 2 minutes for darkroom fog test, look for any sources of
extraneous light. Any light leaks identified should be repaired as soon
as possible.
6. Inspect the processed film. If there is no discernible delineation
between the shielded and unshielded sides of the film, there is no fog
7. If a line is evident, measure the optical densities of both sides of the
line with the densitometer. If the density difference is greater than
0.05, corrective action should be taken.
8. Record results on the Semiannual QC Checklist.
Corrective Action: Repeat the test with the safelight off. If the results
remain the same, the problem may be caused by a light leak or extraneous
light. If the fog level disappears, the fog was due to the safelight and
remedial action must be taken to correct the problem.
Possible Sources Of Darkroom Fog:
- Safelight filters (old or compromised) - Radios
- Safelight housing - Fluorescent light afterglow
- Safelight too close to work area - Light leaks
- Light bulb of incorrect wattage or type - Suspended ceilings
- Ancillary indicator lights on processor - Timers
- Any place there is a hole cut in the wall
- Excessive ambient light through the tinted viewing windows of daylight

7.11 Screen-Film Contact Test:

Objective: To assure that optimum contact is maintained between the
screen(s) and film in each cassette.
Suggested Performance Criteria: No large areas (> 2 cm in diameter) of
poor contact.
1. Acceptance testing for new cassettes
2. Annually
3. As needed, if reduced image sharpness is suspected
Required Equipment:
1. Brass or copper mesh screens (1/8 inch or 3 mm spacing). The mesh
be as large as the largest cassette to betested. The mesh can be placed
between two thin sheets of acrylic or cardboard to protect it.
2. Densitometer
1. Load cassettes to be tested and let rest for approximately 15 minutes
to allow trapped air to escape.
2. Place the cassette on the table and collimate the beam to the cassette
3. Place the wire mesh on top of the cassette and expose the cassette.
(Suggested technique factors are: 5-10 mAs, 50 kVp; 2 mAs, 70 kVp; or
3-5 mAs, 60 kVp).
4. Process the film. The optical density of the area between the wires of
the mesh on the film should be between 1.5 and 2.0.
5. View the film on a in a room with low ambient lighting. Stand 6 to 8
feet away from the illuminator to evaluate the film.
6. Areas of poor contact will appear as dark areas on the film.
7. Record results on the Annual QC Checklist.
Corrective Action:
Large areas (>2 cm in diameter) of poor contact may indicate the need for
corrective action. Clean the cassettes and retest. Areas of poor contact
around the periphery of the cassette may indicate faulty latches or worn
seals on the cassettes. If the area of poor contact is not eliminated by
cleaning, consider replacing the cassette.

7.12 Collimator Test:

Objective: To assure that the light field accurately defines the x- ray field.
Suggested Performance Criteria: The light and x-ray field misalignment
does not exceed 2% of the source-to-image distance (SID) in either the
length or the width of the film.
1. Annually
2. After service or maintenance on the x-ray system (e.g., changing the light
Required Equipment: Includes; i) 8 coins, ii) measuring tape.
1. Place a 10 x 12 inch (24 x 30 cm) loaded cassette at a known SID (e.g., 28
2. If possible, adjust the field size to 6 x 8 inches (15 x 20 cm). The field
must be smaller than the film. If your system is not equipped with a
variable collimator, attach a beam limiting device (BLD) that provides a
field size smaller than the cassette.
3. Place the coins.
4. Expose (65 kVp, 4 mAs) and develop the film. If field edges are not well
defined, adjust techniques accordingly and repeat this step.
5. Measure the distances between the light (where the coins touch) and x-
ray fields for all coin locations.
6. Add differences for each set of coins along and across the film, and divide
each set of differences by the SID (Example: (1.5" along table / 28")(100)
= 5.38% and (0.5" across table / 28")(100) =1.79%).
7. Percentage differences greater than 2.0% in either direction should be
corrected as soon as possible.
8. Using the same exposed film, determine the center of the x-ray field
(darkened portion of film) using a straight edge.
9. In the same manner, determine the center of the film.
10. Measure distance between the two centers and calculate the difference as
a percentage of the SID. If the percentage difference is greater than 2.0%,
corrective action is necessary.
11. Measure the dimensions of the x-ray field on the film. If the difference
between the indicated and measured field size exceeds 2% of the SID,
corrective action is required.
12. Record on the Annual QC Checklist.
Corrective Action: Malfunctioning equipment should be reported to the x-
ray service engineer to correct the problem.

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

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

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


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