Non-Compliance Information for X-Ray Machines

The following are five (5) of the most common non-compliances found during X-ray facility inspections. Included is information as to the intent of the rules as well as how they might be corrected.

1) The dental patient’s head is not visible to the x-ray operator standing in a protected area while making an X-ray exposure.

2) For all types of facilities: X-ray exposure to the patient that exceeds the maximum allowed for the particular body part, patient size, and film/screen speed used by the facility.

Intent of the Rule: To protect patients from unnecessary radiation exposure by limiting the radiation exposure to the minimum amount needed to produce X-ray images of good diagnostic quality. One of the most common causes of this violation is poor X-ray film processing (Developing) resulting in under-development of the X-ray film. In order to obtain a diagnostic X-ray under these conditions, the X-ray operator uses a higher radiation exposure to make up for the under-development in X-ray processing. Some causes of under-processing are:

• An X-ray film processing temperature that is lower than recommended by the film,X-ray film processor, or developer chemical manufacturer.
• Depleted or worn out developer chemistry.
• Developing X-ray films for a shorter time than is recommended by the developer chemistry manufacturer.
  

Correction:

• Make sure that the X-ray film processing temperature is as recommended by the film, X-ray film processor, or developer chemical manufacturer.
• Discard developer chemistry and replace with fresh chemistry per the X-ray film processor, or developer chemical manufacturer’s recommendations. At a minimum , replace at no longer than two month intervals.
• Develop X-ray film at the time and temperature that is recommended by the developer chemistry or automatic X-ray film processor manufacturer.
• Develop and use a Quality Control Program of your x-ray system. As a public service, our Agency has been supplying each dental facility with a quality control device at no cost on a one time basis. This is not to be construed as an endorsement of a particular product, and is only one method of performing quality control for your film processor as well as your x-ray machine.
  
  

3) Poor or no use of or placement of gonadal shielding in Medical/ Chiropractic X-ray facilities.

Intent of the rule: To prevent unnecessary radiation exposure to patient’s gonads (genital area) so that harmful genetic effects are not caused in future offspring. Shielding may not be used for certain types of X-ray examinations or under certain situations because the shielding may block or cover the area of diagnostic interest. However, even when gonadal shielding is able to be used X-ray operators, at times, do not protect the patient’s gonads with lead equivalent shields when X-rays of this particular area (i.e. pelvis, hip, femur, female lumbar spine, etc.) are taken. Some of the reasons that this oversight can occur are because the X-ray operator:

• May have not have been adequately trained regarding the necessity to shield.
• May have not been given adequate directions (policy guidelines) by their employer to enable them to determine in which X-ray examinations that the use of gonadal shielding would block or cover an area the radiologist needs to see.
• May have not been provided adequate shields by their employer.
• May be fearful that they may have to repeat an X-ray (and therefore give the patient unnecessary radiation exposure) because they did not properly place a gonadal shield so that it is effective and does not cover adjacent areas that the radiologist needs to see.
  

Correction:

• The technologist needs to take time to use gonadal shielding when needed.
• Proper education of X-ray operators in regard to gonadal shielding requirements.
• Adequate written policy guidelines need to be established by the employer and given to the X-ray operators.
• Adequate, appropriate, and easy to use gonadal shields should be supplied by the employer.
• X-ray operators must become proficient in the use and placement of gonadal shields.
  
  

4) Fogging of X-ray film

Intent of rule: To prevent poor quality X-rays or repeat X-rays due to darkroom fog. Fogging of the X-ray film is a darkening of the X-ray film due to improper lighting, light leaks, and unnecessary extraneous light sources in the darkroom during X-ray film processing, Fogging of the X-ray film can be to such an extent as to make diagnosis of the film difficult or impossible or to necessitate a repeat X-ray. Film fogging can be caused by:

• Darkroom lights (safelights) that do not have lenses that are compatible with the X-ray film being used by the facility or lenses that have aged and are no longer effective.
• Safelights that have larger bulbs (greater than 15 Watt) than are recommended.
• Safelights that have been mounted closer than is recommended (less than 4 feet) to the workbench where film is unloaded/ loaded .
• White light leaks around doors, the ceiling, recessed lighting, etc.
• Extraneous light from phones, radio dials and buttons, reflective decorations, etc.
• Dental facility automatic X-ray film processors that are designed to be used outside of the darkroom (daylight loaders) that are placed under direct overhead lighting.
  

Corrections:

• Check with your X-ray film manufacturer or supplier to determine which lens type to use. Periodically do a “darkroom fog test” to determine if fogging is present.
• Use white frosted bulbs no larger than 15 Watts in size.
• Mount safelights at least 4 feet from the workbench type.
• Seal off all white leaks.
• Place extraneous light sources so that they do not directly shine upon or towards the X-ray loading bench or cover these sources with black tape.
• Place daylight loader automatic X-ray film processors under subdued lighting.
  
  

5) Inadequate technique charts that result in radiation exposure that exceeds allowable limits/ or that result in unnecessary repeat X-ray exposures to the patient.

The intent of the rule: To keep radiation exposure to the patient to the minimum that is necessary to produce x-rays of good diagnostic quality and to avoid unnecessary radiation exposure to the patient due to repeat X-rays. X-ray operators use technique charts to determine what settings to use of the X-ray machine in order to obtain a diagnostic X-ray. These technique charts are structured by body part, view (i.e. front or side, etc.), and the size of the body part in centimeters. The charts also contain information in regard to the speed of the X-ray film/ screen system being used, the distance the X-ray is to be taken at, and which X-ray examinations require the use of gonadal shielding.Technique charts may be found to be inadequate because:

• The chart has not be designed for use with the speed of the X-ray film/ screen system that is currently being used by the facility.
• The settings indicated on the chart can’t be obtained on the current X-ray machine.
• The chart has not been updated to reflect changes in the X-ray machine (i.e. machine has been recently adjusted by the service person, changes due to aging effects on the X-ray tube, new machine, etc.).
• The chart does not contain all of the required information (i.e. a breakdown of patient sizes and the associated machine settings for each body part, view, and size patient, etc.).
  

Correction:

• Have a new chart constructed that is designed for your current speed X-ray film/ screen system.
• Have a new chart constructed that is designed specifically for the settings on your X-ray machine (i.e. m.A. stations, kVp settings, timer settings, etc.).
• Update the chart at least annually or when a major repair or adjustment is made to the x-ray machine. Note: With age, the characteristics of the x-ray tube will most likely change. As this happens, technique changes will be necessary to maintain film quality!
• Revise the chart or construct a new one that contains all of the required information.