What steps should be taken to resolve a technical x-ray (x-radiation) issue?

Steps to Resolve Technical X-Ray Issues

When facing technical X-ray issues, the first step should be to verify equipment calibration and maintenance, as properly maintained equipment is essential for producing quality images at minimum radiation exposure to patients and personnel. 1

Equipment Calibration and Maintenance

• Equipment should be well maintained and calibration should be surveyed periodically to verify it operates within appropriate specifications 1
• Collaborate with the X-ray system vendor and the institution's radiological physicist to verify detector doses are minimized consistent with optimal image quality 1
• Inaccurate calibrations can seriously affect technique charts, patient exposure, and diagnostic quality of radiographs 2
• Regular quality control tests should include kV accuracy, timer accuracy, mAs linearity, and reproducibility 2

X-Ray System Positioning

• Maintain optimal distance (typically approximately 70 cm) between the patient's skin surface and the X-ray source 1
• Position the X-ray detector close to the patient's chest to intercept scattered radiation and reduce exposure to medical personnel 1
• Avoid positioning the detector substantially above the thorax, as image magnification caused by beam divergence will decrease the size of the beam entrance port, increasing patient skin dose 1
• Optimize system positioning with the procedure table at the optimal distance from the X-ray tube 1

X-Ray System Operational Settings

• Select the lowest-dose imaging modality appropriate for the specific application 1
• Use an image field size that confines exposure to the structures of interest 1
• Use the lowest-dose fluoroscopy program and slowest fluoroscopy pulse rates that yield appropriate quality images 1
• Use the X-ray system collimator to minimize the exposed field size 1
• Employ radiation-sparing tactics including "last image hold," virtual collimator position adjustment, and virtual patient positioning aids 1

Personnel Protection Measures

• Medical personnel working in an X-ray procedure room should wear 0.25- or 0.5-mm equivalent lead aprons augmented with neck thyroid shields 1
• A 0.5-mm lead-equivalent apron absorbs 95% of 70 kVp X-ray and 85% of 100 kVp 1
• Personnel who work close to the X-ray source should wear leaded eye protection with side shields 1
• Implement a radiation protective equipment inspection program to identify and remove damaged protective equipment 3

Dose Monitoring and Awareness

• Be aware of real-time values for air kerma dose rates and cumulative air kerma and KAP (Kerma-Area Product) displayed on current X-ray units 1
• Consider total accumulated dose in making procedure conduct decisions 1
• Monitor the facility's overall radiological performance by tabulating patient procedure doses and personnel doses 1
• Investigate outlier exposures to identify and address their causes 1

Specific Equipment Issues

• For portable X-ray units, designate a specific unit for investigation of suspected infectious cases and leave it within the patient care area to reduce transmission risk 1
• Use direct digital radiography (DDR) imaging whenever possible to reduce transmission risk and minimize radiographer workload 1
• Cover X-ray detector/cassettes with plastic cover or disposable cellophane wrapper and clean between each patient 1
• Check image quality before sending to the picture archiving and communication system 1

Common Pitfalls and How to Avoid Them

• The most commonly failed test in X-ray machine calibration is kV accuracy, followed by mAs linearity 2
• Deficiencies in staff training for equipment operation and optimization techniques are major factors in overexposures 4
• Using checklists and time-outs before procedures commence can provide safeguards to reduce risks 4
• Implement dose alerts when critical levels are reached during procedures 4
• Establish formal policies with clearly defined responsibilities and procedures to identify root causes when incidents occur 4