Radiographic

Inspections
Procedures for Digital and
Conventional Radiographic
Imaging Systems

Lee W. Goldman
Hartford Hospital
Filling in the Gap
 Reasons for Rad or R/F Inspection
 State regulatory requirement
 3rd party payer requirement
 Employer expectations (see following)
 Standards of good practice (see above)

It is not uncommon that “inspections” include the

minimum set of tests and evaluations needed to
fulfill the expectation or legal requirement
(perhaps due to time constraints and priorities)
 Philosophy of Inspections
The goal of radiographic and fluoroscopic (R/F)
inspections should be to provide value by evaluating
and (if necessary) improving:

 radiation safety
 image quality
 image consistency

This may entail going beyond commonly

accepted standards to striving for stricter yet
generally achievable performance levels
 Philosophy of Inspections
Accomplishing this goal require thoroughness
on the part of the inspecting physicist. Since
“time is money”, emphasis must be placed
on:

 efficiency of inspection methodology

 organization of work
 attention to frequent problem areas
Sources of Requirements/Guidelines
Radiographic and Fluoroscopic Units Criteria NCRP AAPM ACR ACMP

Visual Inspection/general CFR Annual Annual Annual Annual

Collimation: CFR Semiann Annual Annual Annual
PBL (if so equiped) CFR Semiann Annual Annual Annual
Grid alignment and focusing Annual Annual Annual Annual
Light field illumination CFR Annual Annual --- ---
Half-value Layer CFR Annual Annual Annual Annual
Exposure timer accuracy CFR Annual Annual Annual Annual
Exposure reproducibility CFR Annual Annual Annual Annual
Exposure rates (mR/mAs): Annual Annual Annual Annual
mA/mAs Linearity:# 0.1 CFR Annual Annual Annual Annual
kVp accuracy Annual Annual Annual Annual
Focal spot size New New --- Annual
SID Indication Accuracy CFR Annual Annual Annual Annual
AEC (phototiming): Semiann Annual Annual Annual
Fluoro min source-skin distance CFR Annual Annual Annual
Max fluoro entrance exposure rates (EER) CFR Semiann Annual Annual Annual
Typical EER measurements Semiann Annual Annual Annual
Spot film exposures and rates Semiann Annual Annual Annual
Automatic brightness control function Semiann Annual Annual Annual
Fluoro resolution and sensitivity Semiann Annual Annual Annual
Fluoro/TV system lag, flare Semiann Annual Annual ----
 Guidelines and Acceptance Limits
 Many items commonly evaluated physicists have
performance levels specified by the Code of
Federal Regulations (CFR) 21 Part 1020
 For other items, recommendations from various
organizations (AAPM, etc)are fairly consistent
 State law may impose stricter limits, require more
frequent evaluations and include more test items
 If not legally mandated, acceptance criteria may
depend on environment, equipment used, etc.
 Might recommend stricter criteria if reasonably
achievable and provides appropriate benefits
 Efficiency of Methodology
 Combination of tests where appropriate
 Time saving tools
 Minimizing cassette/film usage (trips to the
darkroom)
 Organization of Work
 Concise data forms: avoid multiple pages
 Sensible order: verify detents before AEC tests
 Effective reports: Clear summary, recommendations
MODEL:____________________________________MAX mA:___________________ SURVERYOR:_______________
TUBE SER #:______________________________ CHAMBER:_________________ CHAM CF:__________________
KVP ACCURACY AND EXPOSURE (mR/mAs): Focal-Chamber Distance:
SELECTED TECHNIC MEASURED KVP EXPOSURE (mR) CF:
kVp mA Sec mAs kV-1 kV-2 kV-3 AVG mR-1 mR-2 mR-3 AVG CF mR/mAs
60

80

100

120

EXPOSURE LINEARITY, REPRODUCIBILITY AND TIMER ACCURACY: kVp:_________

Frequency of Radiographic Findings
Year Total Collim kVp Reprod Linear Timer SID Grid Fog

2003 33 9% 30% 9% 24% 6% 6% 33% 0%

2002 34 18% 21% 6% 21% 3% 12% 35% 6%
2001 43 26% 30% 2% 35% 2% 12% 42% 0%
2000 38 26% 24% 5% 32% 5% 5% 42% 0%
1999 33 36% 18% 15% 27% 6% 6% 39% 6%
1998 38 39% 11% 3% 13% 3% 3% 29% 11%
1997 17 18% 12% 12% 12% 6% 6% 24% 0%
1996 24 33% 29% 0% 17% 0% 0% 33% 8%
1995 31 26% 32% 0% 35% 3% 0% 13% 6%
1994 25 28% 28% 8% 28% 4% 4% 8% 8%

Total: 316 26% 24% 5.7% 25% 3.8% 5.7% 31% 4.4%

Other: mR/mAs (1), HVL (1), Focal Spot (1), Artifacts (2)
Inspection Factors for Digital Systems
 Many inspection components--no difference
– kVp, mR/mAs, linearity, timer accuracy, HVL)
 For beam measurements (kVp, mR/Mas, etc)
– Move tube off of digital receptor if possibile
– If not, use lead blocker
 Some (may) require digital receptor to record
– Collimation
– Grid alignment
– Focal spot size
– SID Indication ---?
Cardboard Cassettes or ReadyPack
 Radiographic Inspection
Components
 Visual Inspection
 Beam Measurements (kVp, mR, HVL, etc)
 Receptor Tests: Grids, PBL, Coverage
 Tube Assembly Tests: Collim, Foc Spot, SID
 AEC (table and upright)
 Darkroom Tests (if applicable)
 Visual Inspection
 Visually evident deficiencies
often ignored/worked around
by staff
 Reporting deficiencies often
leads to corrective actions
 Include:
–Lights/LEDs working
–Proper technique indication
–Locks and interlocks work
–No broken/loose dials, knobs
–Any obvious electrical or
mechanical defects
 X-ray Beam Measurements
 kVp accuracy AND reproducibility
 Exposure rates (mR/mAs)
 mA linearity
– Adjacent station
– Overall
 Exposure control
– Timer accuracy
– Timer and/or mAs linearity
 Reproducibility
 Half-Value Layer
 kVp Evaluation: Significance
Total kVp Reprod
 Among most common issue,
2003 33 30% even with HF generators
9%
2002 34 21% Poor kV calibration can:
 6%
2001 43 30% 2%– Increase dose if kV’s too low
2000 38 24% 5%
1999 33 18%
– Cause poor mA linearity,
15%
1998 38 11% 3%leading to possible repeats
1997 17 12% Image contrast: affected, but
12%
1996 24 29% 0%
relatively minor effect for
1995 31 32% 0%
1994 25 28%
ranges of miscalibration
8%
usually encountered
Total: 316 23.7% 5.7%
 Causes of kV Miscalibration
 Inadequate provisions for kV adjustments
– May have only one overall kV adjustments to
raise or lower all kVps and one to adjust kV ramp
– Result: difficult to properly calibration all stations
 Miscalibrated compensation circuits:
– Initial sags or spikes as tube begins to energize
– May significantly affect short exposure times
 Important to evaluate kV accuracy at several
mA/kV combinations, and possibly all mA’s.
 Causes of HF kVp Miscalibration
 Pulse freq calibration: infrequent but seen on units
invasively calibrated at generator rather than at tube
 Power line limitations: more common if powered by 1-
phase line with inadequate power
 Units incorporating energy storage device helps
Measuring kV: Yesterday
Measuring kVp: Today
 kVp Measurements (Con’t)
 Invasive measurement:
– still standard for many service personnel)
 Non-invasive kV meters (highly recommended):
– Measurements at many settings practical--allows
comprehensive eval of accuracy & reproducibility
 Understand characteristics of your kV meter
– Minimum exposure time for accurate measurement
– Accuracy ~2%: beware of imposing tight limits
– Effect of mid- or HF (meters that sample waveform)
– Selection of waveform type
– Properly calibrated filtration range
 Effect of Filtration on kV
Meters

mm added Measured kVp

Filtration Meter 1 Meter 2 MultiFunc

0 79.2 80.1 79.1

2 AL 79.8 82.5 79.2
0.1 Cu + 1 Al 81.1 84.8 79.2
0.2 Cu + 1 Al 83.8 82.2 79.3
 kVp Waveforms
 Obtainable with meters having computer output
 Very useful to recognize cause of calibration
problems(ramps, spikes, dropped cycles or phases)
kV Waveform

70
60
50
40
kV

30
20
10
0
0 10 20 30 40 50 60
m illiseconds
 kVp: Action Limits
 CFR: refers only to manufacturer’s specifications
 Manufacturer specs: often quite loose (eg, +/-7%)
 Common recommendations: 5% or 4-5 kV
 For consistency:
differences between kV calibration at different mA
stations may be more important than across-the-
board errors: eg:
100 mA --> 80 kVp measured to be 84
200 mA --> 80 kVp measures to be 76
Both may yield similar intensities at receptor!!
kVp Action Limits-Considerations
 Inconsistencies may be more important than
across-the-board errors
 More important for multi-unit sites (technique
consistency matters more)
 Older Generators:
– Often difficult to accurately calibrate all mA/kV
– Recalibrations may shift error to other ranges
– More important to accurately calibrate limited
but clinically important limited range
 May attempt improvements during next service or
during servicing for other corrective actions
 X-ray Beam Measurements
 kVp accuracy AND reproducibility
 Exposure rates (mR/mAs)
 mA linearity
 Exposure control
 reproducibility
 Half-Value Layer
 Beam Exposure Measurements
Year Total Repro Linear Timer PROBLEM FREQUENCIES
 Poor linearity (adjacent or a
2003 33 9% 24% 6%
2002 34 6% 21% 3% common problem
2001 43 2% 35% 2%  Timer and Reproducibility
2000 38 5% 32% 5%
1999 33 15% 27% 6%
issues occur less frequently
1998 38 3% 13% 3%  Problems may appear only:
1997 17 12% 12% 6% – with certain mA settings
1996 24 0% 17% 0%
1995 31 0% 35% 3%
– Under certain conditions
1994 25 8% 28% 4% – At certain kV ranges
Important to evaluate
Total: 316 5.7% 25.3% 3.8%
Other: mR/mAs (1), HVL (1)
many kV/mA settings!!
 Efficient Beam Measurements
 Valuable to make both kV and exposure
measurements at many kV/mA settings.
 Appropriate to measure kV and exposure
measurements simultaneously.
 May accomplish this via:
– Appropriate (multipe) tools and test geometry
– Multifunction meters
 Efficient Beam Measurements

Multiple Meters
Geometry with Multiple Detectors
 Scatter from kV meter
(or other material) can
significantly affect
exposure measurement
 Procedures:
– Tight collimation
– Block scatter from
dosimeter (air gap,
foam spacer, lead
blocker
Efficient Beam Measurements
Multifunction Meters
 X-ray Beam Measurements
 kVp accuracy AND reproducibility
 Exposure rates (mR/mAs)
 mA linearity
 Exposure control
 reproducibility
 Half-Value Layer
 Exposure Rates (mR/mAs)
 Measure at several mA/kV settings covering
the commonly used clinical ranges
– Can measure along with kVp (no add’l exposures)
– Measure at relevant distance (eg, 30”)
 Normal ranges very broad:
– Affected by filtration, age, kV and mA calibration
– Common range (30”): 12 +/- 50% (3-phase, HF)
– Narrow limits which have been published (6
mR/mAs +/- 1 at 100 cm) are not realistic
 Greatest value is for patient dose estimates
 X-ray Beam Measurements
 kVp accuracy AND reproducibility
 Exposure rates (mR/mAs)
 mA linearity
 Exposure control
 reproducibility
 Half-Value Layer
 Evaluating Linearity
Both adjacent-station linearity as well as overall
linearity (between any two mA stations) are important
 mA Linearity (con’t)
 Definition:
L = (RmA-1 - RmA-2)/(RmA-1 + RmA-2) where R
is mR/mAs at mA-1 and mA-2
 Usual Requirement: L < 0.1 for any pair of
adjacent mA stations
 Exposure rates may differ by ~20% yet pass
 Prob signif contributor to technique errors
 We recommend: L < 0.1 for any pair of mA

L < 0.05 for adjacent pairs

 mA Linearity (con’t)
For some HF and Falling Load Generators:
 Don’t allow selection of mA
 May allow selection of load:
– 60%/80%/100%
– Low/Half/Full, etc)
May evaluate linearity for different load
Note: For these (and some other HF) units,
linearity of mAs rather than mA may be
more pertinent
 X-ray Beam Measurements
 kVp accuracy AND reproducibility
 Exposure rates (mR/mAs)
 mA linearity
 Exposure control
– Timer accuracy
– Timer or mAs linearity
 reproducibility
 Half-Value Layer
Timer Accuracy
Exposure Control & Timer Accuracy
 Measure as part of linearity tests
– Also at longer and shorter times if necessary
 For HF generators:
– exposures terminated at desired mAs, not time.
– More meaningful to evaluate exposure control
via linearity of exposure versus mAs
 Timer Accuracy: Action Limits
1-Phase 3-phase
>10 mSec < 10 mSec
CFR Manuf Manuf Manuf
AAPM1 Not specif 5% 10%
ACMP2 Not separately specif 5% 20%
NCRP 3 1 pulse if >1/20 sec 5% 5%
0 pulses if < 1/20 sec
Hendeei4 1 pulse if >1/10 sec 5% 20%
0 pulses if < 1/10 sec
1
- AAPM Report 74, July 2002
2
- ACMP Report #1, Jnauary 1986
3
- NCRP Report 99, December 1988
4
- HEW Publ (FDA) 79-8094
 Recommend:
– Greater attention to mAs and timer exposure linearity
– Attention to accuracy of short exposure times
– Awareness of non-invasive timer characteristics
 X-ray Beam Measurements
 kVp accuracy AND reproducibility
 Exposure rates (mR/mAs)
 mA linearity
 Exposure control
 reproducibility
 Half-Value Layer
 Reproducibility
 Usual Criteria: coeff of variaton < 0.05
 Our experience: Rarely a problem per se
 Causes when found:
– Abnormally terminated exposures (errors)
– Tripped circuit breaker
– Often occur only at certain technique settings
 CFR test: 10 exposures within 1 hour,
checking line voltage prior to each exposure
 We recommend: limited test (3 exposures) at
several settings, with followup if necessary
 X-ray Beam Measurements
 kVp accuracy AND reproducibility
 Exposure rates (mR/mAs)
 mA linearity
 Exposure control
 Half-Value Layer
 HVL Measurement
 Failures do occur
 Should test new tubes
prior to clinical use
 Test procedure should
allow easy setup, proper
geometry (adequate
space between dosimeter
and aluminum sheets
 Measure at desired
measured kVp
 Criteria from CFR
 Collimation
 X-ray/light field congruence and alignment
 Light field Illumination
 Anode cutoff
 Damaged off-focus radiation limiters
 Positive Beam Limitation
Collimation: Congruence
Collimation: Congruence
 Simple tools can suffice
 Relatively frequent issue,
particularly for portables
 Some uncertainty in
marking light field edges
 CFR Criteria: 2% of SID for
L/X congruence and
indicator accuracy
(1.5” at 72” SID !!)
 Can usually do better: try
for 1% of SID congruence
 Light Field Illumination/Contrast
 CFR Specifications:
– Illum: >160 lux at 100 cm
– Contrast: I1/I2 > 4 (I1,I2
are illuminations 3 mm in
and out from light edge,
respectively)
 Often never inspected
 Common problem on
some collim designs
 Recommend: test if
visually dim or edge
definition is poor
Anode Cutoff and Off-focus Limiters
 Evaluated from full-field exposures:
– both lengthwise and crosswise orientations
– May combine with PBL or grid alignment tests
 Anode Cutoff: failure to reach anode edge of film
with adequate intensity
 Off-focus limiters:
– Can become bent inward, blocking primary x-ray
– Poorly delineated edge of x-ray field occuring
before reaching each of image receptor
 Positive Beam Limitation
 No longer FDA-required
 Still available/common for non-digital systems
 Test for each cassette size
 Can often use single test cassette by overriding
PBL or switching to manual mode
 Place angled cassette on table of in front of
receptor to capture full field
 Limits: from CFR
 Common causes of Failure:
– Mechanical failure of sensors
– Calibrated for metric but english sizes used, etc
 Measurement:
–OK to use star pattern test
with digital image but
Focal Spot Size
–difficult to properly expose
with NEMA kV, mA (need
lowest mAs, 1 mm Cu)
 Results rarely useful
 Pinhole/slit tests:
–Not clinically relevant
–Needed to resolve failure
 Resolution-based test
(as in MQSA) at appropriate
distance/position could be
useful (limits?)
 SID Accuracy
 Measurement:
– Location of focal spot usually not marked or visible
– Determine magnification of known-object size:
convenient to combine with star pattern f.s. test
– Digital displays: should check 2-3 distances
 Criteria: 2% of SID
 Causes of failure: New installations:
– incorrectly located/mounted scale
– miscalibrated digital display
 Causes of Failure: Existing installations
– incorrect or mispositioned tape measure
– Incorrectly used tape (tape handle ‘tip’ or ‘flat’)
 Grid Alignment/Appropriateness

Common problem area due to:

 Incorrect grid: 72” upright grid for orthopedic office
 Angulation due to installation errors or sag (with age)
 Incorrect lateral detents (table and upright receptors)
 Stationary grid artifacts with CR (“corduroy” effect)
 Grid Cutoff vs Lateral Misalignment
Grid cutoff (absorption of primary x-rays) versus amount of
lateral decentering of x-ray tube focal spot from the grid focal
line. Lateral decentering is relatively common due to
misplacement or changes in detent positions (measurements
are for a typical 10:1 grid, 103 lines/inch)

Distance (in): 0 0.5 1 1.5 2 2.5 3 3.5

% absorbed: 0% 12% 24% 41% 53% 71% 82% 92%
Stationary Grid Artifacts with CR
 Problem if grid
lines parallel to
CR horizontal
scan direction
 Need > 65-70
lines/cm for
clinically
acceptable
images
 Testing Grids
 If exposure possible with tube off lat detent:
– Load cassette crosswise in receptor
– Position x-ray at lateral detent and proper SID
– Expose (~3 mAs at 50 kVp) with full x-ray field
– Repeat with lateral shift of +/- 1” and +/-2”
– Can use one cassette, exposing narrow strips
– Maximum density of signal should be at detent
– Image density or signal should be rel uniform
 If cannot move off detent:
– one exposure--should have relatively uniform
signal or density across image
 Radiograpic Inspection: Summary
1) Visual inspection and recording of information
2) kVp and mR/mAs together at 4 kVs, 3 mA’s
3) mR at fixed mAs for all mA; also measure time, kVp
4) HVL measurement
5) Light/X-ray field alignment
6) Star pattern focal spot test with SID verification
7) PBL test with film 14x17” test inspected for coverage
8) Grid alignment (also inspected for coverage)
9) Table and upright receptor AEC tests (if applicable)
10) Darkroom fog evaluation (if applicable)
11) Vendor-specific digital receptor tests, if available
 Portable Radiography Inspection
 Battery-powered: Ports Total HVL Collim kVp Reprod
– mR/mAs and kV 2003 7
formerly frequent 2002 5 20% 20%
problems; rare with 2001 8 13% 13%
2000 9 11% 11% 11%
modern versions
1999 9 56% 33% 11%
 Capacitor-discharge 1998 10 10% 30% 20%
– More uncommon 1997 4 50% 100% 50%
1996 3 33% 33% 67%
– Difficult to test 1995 4 25% 50% 25%
 Outlet-powered and 1994 4 25% 25%

all portable types:

Total: 63 10% 32% 22% 3%
– Collimation most Other: mR/mAs (0), Reprod (0), SID (0)
frequent problem Linearity (NA), timer (0), Foc Spot (0)