A Clinical Audit on the Compliance with the Innovated Manual Processing X-Ray Film Technique using...

IJIRST –International Journal for Innovative Research in Science & Technology| Volume 3 | Issue 04 | September 2016 ISSN (online): 2349-6010

All rights reserved by www.ijirst.org 86

A Clinical Audit on the Compliance with the

Innovated Manual Processing X-Ray Film

Technique using Darkroom

Raditya Faradina Regidor III Dioso

Lecturer Lecturer

ATRO, Indonesia & Lincoln University, Malaysia Lincoln University, Malaysia

Abstract

This clinical audit identified darkroom users’ compliance with the innovated manual processing film technique and evaluated it’s

effectiveness in decreasing risks of repeating unnecessary x-ray shooting. The steps in the standard operating procedures of

radiography, good manual processing film technique, practical protection measures and manual processing film practice in

darkroom were audited. Twenty-eight participants were randomly selected. The demographic distribution is divided into, gender,

semester and practice experience. Generally, of the 28 students, there were 18 who complied (64.3%) than those who did not

comply (10 or 35.7%). Compliance rate was more likely probable (p=0.04) than that of the non-compliance (p=0.157). The

factors affecting quality of film processing that was done by the students included film positioning technique, exposure

technique, processing film technique, and film exposure to light.

Keywords: Applied Science, Clinical Audit, Darkrooms, Innovation, Radiographic Images, Radiography

_______________________________________________________________________________________________________

I. INTRODUCTION

This innovation – manual processing film technique in the darkroom – is a quality improvement process that is anticipated

to reduce the over/under density, and artifact found in the film radiograph image. Many radiographers who utilize manuals for

processing x-ray films, intentionally in an attempt to save time, results in radiographs that are inferior in diagnostic quality

because of incomplete developing [1]. When an X-ray film has been exposed, it must be processed in order to produce a

permanent visible radiographic image that can be kept without deterioration for a number of years [1, 2]. Processing transforms

the latent image into a visible image that undergoes developing, rinsing, fixing, washing and drying procedures – the innovated

manual processing film technique in the darkroom.

On account of these issues, this clinical audit aims to identify darkroom users’ compliance with the innovated manual

processing film technique and evaluate its effectiveness in decreasing risks of repeating unnecessary x-ray shooting. It also aims

to identify which demography, such as gender, level of education and clinical practice experience complies with the practice of

the innovated manual processing film technique in the darkroom.

According to Jones and Cawthorn [3], when clinical audit is conducted well, it provides improved methods and/or systems

(the innovated manual processing film technique in darkroom) in which the quality of procedure for processing x-ray films

becomes supportive and developmental. Therefore the innovated manual processing film technique for darkroom is anticipated

to improve and develop the practice of processing film technique among darkroom users. A conclusion is offered.

Processing is a series of actions by which exposed X-ray film yield an image [4, 5, 6]. In processing a film, according to ICRP

Publication series 34/60/73, the sequence of actions for the innovation should be as follows:

Transfer of the film to hanger (for wet film developing).

1) Developing, the film should be put into a tank of developer and moved up and down once or twice in the tank.

2) Rinsing, after developing, the film should be rinsed for about 30 seconds in clean water. During this time the film should be

lifted up and down several times in the water tank. Remember: there should be no bright light in the darkroom.

3) Fixing, is done after the film has been rinsed, it should be put in the fixing tank. The film should stay in this tank for at least

5 minutes (the film will not be damaged if it is left for longer than 5 minutes). There must be no white (even low) light in

the darkroom for the first 3 minutes of fixing time.

4) Steps 1-4 must be carried out with only the safelight turned on.

5) Washing is done after it has been fixed, the film should be washed in the large washing tank (this tank usually has clean

running water). The film should stay in the water thank for at least 30 minutes. It will not be damaged if it is left for longer

than 30 minutes.

6) At this time the white lights may be turned on, however, provided that there are no other films are being processed.

7) Drying is done after the film is ready to be air blown. The air drying temperature must not exceed 300C and the film must

be hung in a dust-free area.

A Clinical Audit on the Compliance with the Innovated Manual Processing X-Ray Film Technique using Darkroom (IJIRST/ Volume 3 / Issue 04/ 015)


8) Checking opacities and over exposure is the last step. Too much whitish discoloration or noises (dirty pictures) if not too

dark are both considered rejected x-ray films.

9) Sort out acceptable x-ray films and discard the rejected.

II. METHODOLOGY

Primarily the authors audited the innovated manual processing film technique in the darkroom. The participants involved in the

audit are the students in semester two and four. Subjects’ selections were simple and random.

Secondly, the auditors ensured that the innovation was presented to the operations management for approval which is then

shown to the deans to ensure that it is operational and in coordination with the lecturers’ or x-ray laboratory and darkroom

instructors’ schedule. The auditors will also make sure that the darkroom laboratory were supplied with facilities such as films,

cassettes, hangers, wall mercurial thermometers, tank contain developer, trash bins (for radiation), gowns, gloves, fixers and

clean running water supply.

Steps of the innovated manual processing film technique in the darkroom are posted on the walls of the selected laboratories

with the seal of approval from the academy operations management. The posters are to be 3 feet long and 2 feet wide such as the

A-3 sized papers and the letters are typed in big font size 40 written both in the Indonesian and English language. It is anticipated

that the laboratory instructors will emphasize to their students to comply with the approved innovated manual processing film

technique in the darkroom.

Finally, an additional risk of safety for human subjects was approved by the department of research and gave a copy to the

operations management to commence the audit.

The audit will be a maximum of 7 days. Since the auditors (in this case, the authors) used 14 students in semester 2 and 14

students in semester 4, so the total number of participants were 28. The auditor ensured that the audit will not be repeated since

the prospective subjects – both students semester 2 and 4 – will already be informed that they are being observed.

Portfolios of the participants were organized and it is ensured that it follows the guidelines of the Quality Assurance Agency

[7]. Each participant was given index numbers for data analysis. Each index number will be given to the participants so that

when they wish to refer back to the results of their published findings in this clinical audit, the portfolio will be easily accessed.

Prospective subjects/participants who will not comply with the method of the manual processing in the darkroom will belong

to the category of the non-compliance, while those who comply will belong to the category of compliance.

After the enrolled participants use the darkroom, whether they complied with the procedure following the innovated manual

processing film technique in the darkroom or not, will conclude the evaluation.

Collecting the radiographs films after processed in the darkroom are labeled as compliance and non-compliance (Fig. 1) as a

part of data analysis. If the films show over opacity and / or over exposure with a lot of whitish or darkened discoloration, it is

considered as non-compliance. Another system of analyzing the data collected used central tendencies upon identifying the

number of compliant human-users against the non-compliant. The identified findings are quantitatively evaluated.

III. FINDINGS

Twenty-eight participants gave consent to be audited. The participants who belonged to the non-compliance category have

developed films that are either over exposed or dense in opacity. Those who demonstrated all the steps of the innovation

belonged to the compliance category.

Table1 shows the identified demographic distribution of the 28 participants categorized to be compliant and non-compliant

with the innovated standard procedure manual processing film technique in the darkroom.

Of the 28, it was evaluated that there were more participants who complied (18 or 64.3%) than those who did not comply (10

or 35.7%). There were more male students who complied (10/14) as compared with female students (8/14). Participants who are

male high school (Science majors) comply most on the method (7 complied), followed by the female high school (Science

majors) (6 complied). There were more female who did not comply from high school of social majors (5 non-compliance)

followed by the high school of science majors (2 non-compliance). The males from high school science and social majors were

likely non-compliant (4/28). There were more student in semester four who complied (13/28) as compared with those who were

student in semester two (5/28). The statistical figures identify compliance of manual processing film technique in the darkroom

using the mean, standard deviation (σ) and probability (p) set at 95% confidence with a 0.05 margin of error.

Data analysis using central tendencies evaluated compliance rate to be more likely probable (p=0.04) than that of the non-

compliance (p=0.157). However, a deviation to perfect compliance (2.06) was found. Table – 1

Compliance and Non-Compliance to the Innovation

Category Semester 2 Semester 4

mean σ p Female Male Female Male

Compliance 2 3 6 7 4.5 2.06 0.04

Non Compliance 5 4 1 0 2.5 4.25 0.157

It was also identified that the participant in the 4th semester had more experience on developing x-ray films in the dark room

because they are already exposed in several hospitals as clinical placements; while the 2nd semester students have limited



exposures to x-ray film developing in their clinical exposures. Lastly, it was identified that the factors affecting quality of film

processing done by the students include film positioning technique, exposure technique, processing film technique, and film

exposure to light [4, 5, 6]. Fig. 1 shows the comparison of density and noise artifact between compliance and non-compliance.

Fig. 1: Comparison of Compliance and Non-Compliance

IV. ACTION PLAN FOR CHANGE MANAGEMENT

The innovated manual processing film technique in the darkroom audited in this private academy in Indonesia must use a

handbook to enhance learning in the workplaces annually. However, the handbook must achieve the aim to provide an element

of professional practice pertinent to reducing the errors on manual processing technique. This distinguishes the challenges of

implementing the innovation.

Auditing the correct way of using the apparatuses to manual processing film techniques are the primary step. However, the

process of change can be threatened if the user does not have the full knowledge about manual processing film techniques. In

order to avoid this weakness the auditors after conducting the audit, ensure that the standard operating procedures are explained

to the darkroom users monthly.

However, to demonstrate competency in complying with the innovation, the auditors will give the students semi-annual

seminars and trainings to emphasize on the innovated manual processing film technique in the darkroom.

It is anticipated that those who attended the seminars and trainings will disseminate the information and/or their knowledge of

the innovation to their friends who uses the darkroom as their work places.

These darkroom users (whether it be students in second until fourth semester) will be identified as potential harm to the

anticipated success of the change process, if they will not comply with the innovated manual processing film technique in the

darkroom after semi-annual seminars and trainings.

Hence, clinical audits must be constantly conducted semi-annually to freeze the change process (table 2). Table – 2

The clinical audit that must be constantly conducted

What we want them to do (Innovated radiographic

techniques)

What they are doing

(Findings) What they need to do (action plan)

Turn off the room lights and lock the door Complied

Not Complied

Read the handbook and attend seminars

and trainings

Use hanger to clamp the films according to the size of

film used

Complied

Not Complied Read the posters on the walls

Put the film into a tank of developer and moved up and

down once or twice in the tank

Complied

Not Complied


and trainings

Do Checked against latent shadows under safe light. Complied

Not Complied


and trainings

Put the film into rinsed for about 30 seconds in clean

water.

Complied

Not Complied


and trainings

Put the film in the fixing tank and should stay in for at

least 5 minutes

Complied

Not Complied


and trainings

Washed the film in the large washing tank for at least

30 minutes

Complied

Not Complied


and trainings

The film must be to be dried with temperature must not

exceed 300C

Complied

Not Complied


and trainings



V. CONCLUSION

Of the 28, 14 are male participants and 14 are female participants. Compliance rate are evaluated to be more likely probable

(p=0.04) than that of the non-compliance (p=0.157).

On the other hand, it was identified that the factors affecting quality of radiograph during radiographic examinations include

applied positioning technique, exposure technique, processing film technique, and film exposure to light [7] which needs to be

addressed among radiographers to take into consideration.

It is therefore concluded that auditing innovated manual processing film technique in darkroom is deemed necessary to

evaluate quality radiographic image. Since Radiographic image quality is the exactness of representation of the patient’s

anatomy on a radiographic image to diagnose diseases or abnormalities [1, 7].

The innovated manual processing film technique in darkroom was successful although this audit still identified a percentage of

deviation from the point of perfect compliance due to lack of skills competency.

Effective programs in diagnostic radiology enables the achievement and maintenance of obtaining radiological information of

appropriate quality radiographic image for the purposes of medical diagnosis, minimizing doses received by humans and medical

personnel [8]. Improvement of professional and public reputation of radiological department as a result of education and active

work approach [1, 2, 7, 8] is also important to be considered.

REFERENCES

[1] Dunn, M. A., & Rogers, A. T. (1998). X-ray film rejects analysis as a quality indicator. Radiography, 4, 29e31.

[2] Zoetelief, J., Fitzgerald, M., Leitz W. and Säbel M. ‘European Protocol on Dosimetry in Mammography’, Report EUR 16263, 1996. [3] Jones, T. and Cawthorn S. (2002). "What is clinical audit.". Evidence Based Medicine. Hayward Medical Communications. 2(12): pp.11-19.

[4] ICRP Publication 60. ‘1990 Recommendations of the International Commission on Radiological Protection’. Annals of the ICRP Vol. 21, Nos 1-3 (Oxford, Pergamon Press).

[5] ICRP Publication 34, ‘Protection of the Patient in Diagnostic Radiology’, Annals of the ICRP Vol. 9, Nos 2-3 (Pergamon Press, Oxford), 1982.

[6] ICRP Publication 73, ‘Radiological Protection and Safety in Medecine’, (Pergamon Press, Oxford), in press. [7] Moores BM, Wall BF, Eriskat H and Schibilla H, eds. Optimization of image quality and patient exposures in diagnostic radiology. London: British

Institute of Radiology 1989

[8] Watkinson, S., Moores, B. M., & Hill, S. J. (1984). Reject Analysis: Its role in quality assurance. Radiography, 50, pp. 189-194.

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