International Commission on Radiation Protection (ICRP) recommends that medical exposure should be kept as low as reasonably achievable considering economic and social factors (ALARA) and one way of achieving this is through film reject analysis.  The aim of radiography is to obtain images which are adequate for clinical purposes with minimum radiation dose to patient. The Conference of Radiographic Control Program Directorate (CRCPD's) committee on Quality Assurance (QA) recommends a higher reject rate of 10% Joseph et al. (2015).

The World Health Organization (WHO) defined Quality Assurance (QA) as an organized effort by the staff operating a diagnostic facility to ensure that diagnostic images produced by the facility are of high quality so that they consistently provide diagnostic information at the lowest possible cost and with the least possible patient exposure to radiation. Film reject analysis is an essential part of QA in any large X-ray department. Firstly, it will indicate weak areas of radiographic and radiological practice in the department, secondly, reject analysis will enable one to note any improvement after quality assurance measures have been put into practice Teferi et al. (2010).

                                         

2.     MATERIALS AND METHOD

The materials used in this study were radiographs (both good and rejected radiographs) and Viewing box. Rejected radiographs consisting of both adults and pediatrics radiographs were collected from three different hospitals in Jos, Plateau State between December 2018 and December 2019. The rejected radiographs consisted of the basic x-ray projections (Antero-Posterior (AP), Posterior-Anterior (PA), and Lateral). The films were assessed on a viewing box and under similar conditions of room light and temperature. Rejected radiograph were analyzed and categorized based on body parts that included; chest, skull, knee, lumbar sacral, shoulder, neck, femur and pelvis. The reasons for rejection were categorized as: over exposure, under exposure, poor processing, poor positioning, wrong placing of anatomical marker, fog, artifact and multiple exposures. The studied Hospitals (selected by convenience) were: Na Allah Nakowa Hospital, H1, General Hospital Mangu, H2, Plateau state Hospital, Jos, and H3.

 

Reject rate

The reject rate for each hospital respectively was calculated by the formula below Joseph et al. (2015),

Reject rate (%) =  × 100% ------------------- (1)  Teferi S et al. (2010).

 

3.    RESULTS AND DISCUSSION

HOSPITAL H1

A total of 1379 films were used in the radiation facility from December 2018 to December 2019. 122 were rejected films. The results are shown in the tables and figure below;

Table 1 Anatomical Parts of Rejected films
ANATOMICAL PART	NUMBER OF REJECT FILMS	PERCENTAGE %
Chest	53	43.44
Skull	7	5.74
Knee	21	17.21
Lumbar sacral	5	4.1
Shoulder	7	5.74
Neck	4	3.27
Femur	13	10.66
Pelvis	7	5.74
Abdomen	5	4.1
Total	122	100

 

Table 2 Reasons for Rejected films for Hospital H1
REASON OF REJECT	NUMBER OF REJECT FILMS	PERCENTAGE %
Over exposure	31	25.41
Under exposure	46	37.7
Poor processing	13	10.66
Poor positioning	11	9.02
Wrong placing of marker	6	4.92
Fog	8	6.55
Artifact	7	5.74
Multiple exposure	-	-
Total	122	100

 

HOSPITAL H2

A total of 842 films were used in the radiation facility from December 2018 to December 2019. 56 were rejected films. The reject film rate for hospital H2 is 6.65%. The results are shown in the tables below

Table 3 Anatomical Parts of Rejected films for Hospital H2
ANATOMICAL PART	NUMBER OF REJECT FILMS	PERCENTAGE %
Chest	20	35.71
Skull	3	5.36
Knee	2	3.57
Lumbar sacral	13	23.21
Shoulder	3	5.36
Neck	3	5.36
Femur	2	3.57
Pelvis	8	14.29
Abdomen	2	3.57
Total	56	100

 

Table 4 Reasons for Rejected films
REASON OF REJECT	NUMBER OF REJECT FILMS	PERCENTAGE %
Over exposure	8	14.29
Under exposure	17	30.35
Poor processing	13	23.21
Poor positioning	12	21.43
Wrong placing of marker	3	5.36
Fog	-	-
Artifact	3	5.36
Multiple exposure	-	-
Total	56	100

 

HOSPITAL H3

A total of 1411 films were used in the radiation facility from December 2018 to December 2019. 79 were rejected films. Hospital H3 has a reject film rate of 5.60%. The results are shown in the tables below

Table 5 Anatomical Parts of Rejected films
ANATOMICAL PART	NUMBER OF REJECT FILMS	PERCENTAGE %
Chest	20	25.32
Skull	6	7.59
Knee	4	5.06
Lumbar sacral	12	15.2
Shoulder	8	10.13
Neck	8	10.13
Femur	5	6.33
Pelvis	6	7.59
Abdomen	4	5.06
Specials (HSGs)	6	7.59
Total	79	100

 

Table 6 Reasons of Rejected films
REASON OF REJECT	NUMBER OF REJECT FILMS	PERCENTAGE %
Over exposure	13	16.46
Under exposure	25	31.65
Poor processing	12	15.19
Poor positioning	17	21.52
Wrong placing of marker	4	5.06
Fog	3	3.8
Artifact	5	6.32
Multiple exposure	-	-
Total	79	100

 

Figure 1 The Comparison of Rejected films based on Anatomical body Parts for the Hospitals

Figure 2 The Comparison Reasons of Rejected films for the Hospitals

 

 Figure 1 shows that the highest anatomical part rejected is the chest and Figure 2 shows also the highest reason for rejection of radiographs was under- exposure and the least reason for the film reject was wrong placing of anatomical marker in Hospital H1 which could either be due to operator’s technical limitation, or machine fault. The reject film rate of H1 was 8.85%. Study of Charlene et al. (2018) shows that under exposure recorded the highest rate after positioning and chest as the highest anatomical part rejected. Figure 3 also shows the highest anatomical part and the least as chest and abdomen respectively, figure 4 shows the highest reason for rejected films was underexposure and the reject film rate for Hospital H2 was 6.65%. The reject film rate for Hospital H3 is 5.6% with the chest as the highest anatomical part rejected and abdomen and knee as the least anatomical part of the rejected radiographs as seen above in figure 5. Figure 6, shows also the highest reason and least reasons of rejected radiographs was underexposure and fog respectively as seen above in figure 6 for Hospital H3. Finding of this study agrees with the study of Jwanbot et al. (2017) which shows that the highest reject radiographs to be chest (anatomical part) with under exposure as being the major cause of rejection.

Other studies disagree with the results of this study as observed that under exposure was a major cause of rejection of radiographs. Banahene et al. (2017), Nwobi et al. (2011), in their studies reported that over exposure and positioning error were the most occurring reasons for rejection of radiographs. Dunn and Rogers (1998) reported in their study also that patient positioning was the major cause of film reject

The reject rate of Hospital H1, H2, H3 was found to be 8.85%, 6.65% and 5.6% respectively which were above the World Health Organization and within the Conference of Radiation Control Program Directorate (CRCPD) recommended permissible of 5% and (5-10%) respectively.

 

4.    CONCLUSION

From this study, we observed that the anatomical part mostly rejected was the chest and the highest reason of rejected radiographs was under exposure. The reject rate of Hospital H1, H2, H3 were found to be 8.85%, 6.65% and 5.6% respectively which are above the World Health Organization recommended limit but within the Conference of Radiation Control Program Directorate (CRCPD) recommended limit of 5% and (5-10%) respectively. The findings imply that patients might have been exposed to avoidable radiation doses.

 

5.    ACKNOWLEDGEMENT

The researchers are grateful to the management staff of the studied Hospitals for the permissions to carry out the study and the cooperation enjoyed in the course of the study.

 

REFERENCES

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Watkinson, S., Moores, B. M., & Hill, S. J. (1984). Reject analysis: its role in quality assurance. Radiography, 50(593), 189-194. Retrieved from https://europepmc.org/article/med/6484122