Courtney Nance

Repeat Analysis
Quality assurance programs in any imaging department should include a repeat analysis
component. Repeat analysis both helps improve overall performance and reduce patient
exposure. By determining the root cause of problems, employees know where to focus their
efforts for a solution.
February 20th to March 27th, 2014, my repeats were monitored at Valley View Medical
Center. 192 exposures were made with 18 repeats over the course of 1 month, making my total
repeat rate 9.4%. Categories display the causal repeat ratio to sort where improvements can be
made; such as over-exposure, motion and other errors. My repeats tallied in 3 areas: Collimation
11.1%, Artifacts 16.6%, and Positioning 72.2%.
Collimation errors due to small exposure fields in efforts of radiation protection resulted
in clipped anatomy. It is important to note the elongation of structures when angling the x-ray
tube across the imaging receptor. High probabilities of clipped anatomy are made while using a
tightly collimated light field on an axial view. For example, an AP Axial Clavicle requires a 15
cephalad angle. Both the acromioclavicular (AC) and sternoclavicular (SC) joint must be
included on this view. The sternal extremity of the clavicle tends to curve slightly inferior
making it easy to clip. Palpation is important in radiography to determine location of the sight
being imaged. Factoring in elongation, collimation, and palpation would help me to not clip
anatomy followed by a repeat exposure.
Artifacts are common mistakes with students because the focus is stressed on positioning
and technique selection. Reasoning behind artifact errors are due to forgetting to ask for removal
of all items, the patient forgetting a radiopaque object is on them, or certain positions gathering
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Courtney Nance
together clothing. For example, a Tunnel Knee view requires knee flexion of 45. Lightweight
jersey material usually is fine to cover the leg on an AP Knee view. However, clothing bunches
when the knee is flexed, making it visible on a radiograph. Creating a habit to have almost
nothing covering the anatomy of interest whenever possible is best practice.
Digital imaging has dramatically decreased equipment and processing errors. Today the
most common repeat mistake is positioning in imaging departments. Due to my positioning
causal repeat rate being 72.2%, it is my area of focus. Most positioning repeats were due to
incorrect CR centering and rotation of a structure. A majority of repeats were from the knee
where it is pertinent to rotate, flex, and extend the joints correctly. Also, body habitus played a
key role in repeating chest x-rays. Judging whether patients have long lungs, or the apices
starting lower because of muscular shoulders, can play a factor in where to center. Critical
thinking is a quality needed in this profession. While imaging an External Oblique Elbow the
patient had limited mobility. Leaning and dropping the shoulder, which increases external
rotation, did not work with this patient. On the repeat radiograph, an RT taught that lowering the
table enables the patient to lean and increase external rotation. The previous positioning error
could have been prevented by stepping back to assess and find a better solution. Simple
resources can be a great tool, rather than your patient moving to uncomfortable positions.
Palpation and positioning work hand in hand. Using visual cues to determine central ray location
is a start, but palpating is the assured process. A majority of repeats were due to the anatomy of
interest being incorrectly positioned over the image receptor. Positioning comes with experience,
but knowing the components, (angles, positions, tips, and tricks) before entering the exam gives
an advantage. Positioning sponges would benefit me to better determine angles and use as an
immobilization device.
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Courtney Nance
I am able to present strong knowledge and confidence in an exam. Being a determined
hard worker makes me never give up on an exam. Rather, if I do need help, the technologist is
assisting, not taking over. I can relate to the patient making them comfortable before the exam.
However, during the exam, I slack in the area of specific communication for positioning. Giving
more detailed instructions to patients without mumbling would help increase cooperation and
efficiency. It is easy to get caught up in all the details of an exam. In difficult situations its best
to look at the exam as a whole and be able to connect simple ideas with how I should position the
patient and central ray. Awareness of the previously stated items will help improve my skills as a
technologist.