Hrev_master [Healthcare in Low-resource Settings 2023; 11:10575] [page 7] Analysis of the potential reasons for repeated radiography: a study in a major hospital in south eastern Iran Hamid Dahmarde, Marzieh Abiri, Sharareh Sanei Sistani Deparment of Radiology, Zahedan University of Medical Sciences, Zahedan, Iran Abstract Rejecting, removing and repeating the process of taking diagnostic X-ray images could lead to professional and moral chal- lenges in the case of radiologic imaging. The aim of this study was to investigate the common causes of repetitive imaging and the types of images mostly repeated. Radiographs taken in our medical center form January 1st 2021 to July 1st 2021 were evaluated. After gathering information and importing form-related data into the statisti- cal software SPSS Ver. 26. In this study, a total of 4916 were evaluated. Among 398 repeated radiographs, 94 repetitions (23.62%) were due to inappropriate posi- tioning, 92 repetitions (23.12%) were due to patient’s movements, 56 repetitions (14.07%) were due to inadequate radiation, 51 repetitions (12.81%) were due to inade- quate processing, 46 repetitions (11.56%) were due to inadequate preparation of the patient, and 59 repetitions (14.82 %) were due to other reasons. In this study, the rate of repeated radiographs taken in a tertiary hospital was estimated at 8.10%, with the most common cause for repetitions being inappropriate positioning. Considering the fact that repeated radiography mostly depends on operator-related factors, it is recommended to repeat the study after edu- cating staff in order to compare the rate and reason of repetition. Introduction Rejecting, removing and repeating the process of taking diagnostic radiographic images could lead to professional and moral challenges in the case of radiologic imag- ing. Rejection analysis is one of the impor- tant parts of qualification assurance pro- grams in medical imaging departments.1 The analysis is a basis for determining the reason behind the rejection of images and maybe beneficial in radiography-related education, improving quality of work in the radiology department, and finally reducing patients’ exposure to radiation.2 The radio- graphic examination is mostly done in at least two planes in order to gain diagnostic images to help diagnose disorders or dam- ages.3 A rejected image is one considered to have inadequate quality by a radiologist. The radiologist decides that the image does not hold technical standards for a certain diagnosis process and consequently rejects the image demanding another one.4 This recurrent imaging process increas- es the patient’s exposure to radiation and thus violates the concept of keeping ioniz- ing radiation exposure at a fair minimum. Moreover, rejected images reduce the effi- ciency of the department and patients’ con- sent which accordingly increases institu- tional costs.5 Evaluating the rate of repeated images is a part of the rejection analysis process, which is an acceptable standard to assure the quality in general radiology. Observing repeated radiographs can help evaluating the quality of diagnostic images, improving examination protocols, educating staff, and assessing patients’ radiation exposure.6,7 For a diagnostic radiology department to be able to provide images of high quality with the minimum exposure of patients and staff to the radiation, a program of quality assurance needs to be set and accomplished.8,9 The reasons for the rejec- tion of images correspond with technical alternated advances. The most common rea- son to reject images in conventional film- screen radiology was reported to be expo- sure errors (that is, too much or too little exposure).10,11 Currently, this issue is a posi- tion error in computed radiography (CR) and digital radiology. The accuracy of results achieved by rejection analysis depends on radiologists’ obligation to cate- gorize their rejected images appropriately. Also, the ability of the imaging department to reduce the rate of rejected images depends on the application of findings acquired by rejection analysis using a feed- back and education system.12-15 This study reports the repetition rate in an imaging department in Iran. The aim of this study was to investigate the causes for repetitive imaging and to evaluate the types of images mostly repeated. Materials and Methods This study was approved by the ethical committee of Zahedan University of Medical Sciences. The radiographic images taken in radiology department of Ali Ibn-e- Abi Talib hospital, Zahedan, Iran form January 1st 2021 to July 1st 2021 were included. First, a radiology technician was asked not to delete any repetitive images for different reasons and to save them just the same. At the end of each week, repetitive images were referred to the researcher to analyze the frequency of repetitive radio- graphs and the causes. There was a form that the specialist should fill if they want to ask for a repeated imaging where they were provided with 6 options: i) inadequate radi- ation (too much or too little amount of radi- ation), ii) inappropriate positioning, iii) patient’s movements, iv) inadequate pro- cessing, v) inadequate preparation of the Healthcare in Low-resource Settings 2023; volume 11:10575 Correspondence: Marzieh Abiri, Deparment of Radiology, Zahedan University of Medical Sciences, Zahedan, Iran E-mail: 30stana@gmail.com Key words: repeated radiography; rejecting; X-ray images. Conflict of interest: the Authors declares no conflict of interest. Ethics approval and consent to participate: the Ethics Committee of Zahedan University of Medical Sciences approved this study (IR.ZAUMS.REC.1399.314). The study is conformed with the Helsinki Declaration of 1964, as revised in 2013, concerning human and animal rights. Informed consent: All patients participating in this study signed a written informed consent form for participating in this study. Patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient infor- mation to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received for publication: 25 April 2022. Accepted for publication: 21 April 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:10575 doi:10.4081/hls.2023.10575 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guar- anteed or endorsed by the publisher. No n- co mm er cia l u se on ly patient, vi) other reasons. These filled forms were reviewed by a radiologist and in cases where the radiologist was not consistent with the specialist, the issue was discussed with a second radiologist who was experi- ence in that specific field and the final deci- sion was made by him/her. Inadequate pro- cessing includes items such as lack of mark- ing or false marking, false crop, the false record of names and other features of radio- graphic. Other reasons consist of items such as dysfunction of radiology device, cassette size-related problems in portable Images, errors regarding the type of radiography which was asked for, presence of artifacts, and other items leading to repetition. Repeated images were also differentiat- ed based on anatomic areas, including skull, spine, chest, abdomen, hips, and limbs, and the frequency of repetition was analyzed in each as well as their causes (Table 1). It is necessary to mention that radiographs taken of knee, femur, ankle, and foot were all sub- groups of lower limbs, while radiographs taken of the elbow, shoulder, wrist, hand, radius, ulna, and humerus were subgroups of upper limbs. Statistical analysis After gathering information and import- ing form-related data into the statistical software SPSS Ver. 26. statistical indexes regarding descriptive statistics such as fre- quency and percentage were first calculat- ed. The results were then represented as charts and tables. Results In this study, a total of 4916 radiographs were included. Radiographs were catego- rized and assessed in 7 anatomic groups including chest, hips, abdomen, upper limbs, lower limbs, skull and spine. Most of the radiographs among the data obtained were chest images (CXR), of which there were a number of 3060 (62.25%), secondly abdomen (718 images accounting for 14.61%), and thirdly lower limb (472 images accounting for 9.60%). The numbers and percentages of radio- graphs taken of each body area are repre- sented in Table 1. Most frequent repetitions were seen in radiographs of the skull and upper limbs (respectively 8 images accounting for 13.33% and 30 images accounting for 10.34%) while the fewest repetitions occurred in abdominal radiographs (8 images accounting for 1.11%). The num- bers and percentages of radiographs taken of different body areas are represented in Table 1. Reasons of repetition included inade- quate radiation (too much or too little amount of radiation), inappropriate posi- tioning, patient’s movements, inadequate processing, inadequate preparation of the patient, and other reasons. It is necessary to say inadequate processing includes items such as lack of marking or false marking, false crop, the false record of names and other features of radiographic, etc. Other reasons consist of items such as dysfunction of radiology device, cassette size-related problems in portable Images, errors regard- ing the type of radiography which was asked for, presence of artifacts, and other items leading to repetition. Among 398 repetitive radiographs, 94 repetitions (23.62%) were due to inappropriate posi- tioning, 92 repetitions (23.12%) were due to patient’s movements, 56 repetitions (14.07%) were due to inadequate radiation, 51 repetitions (12.81%) were due to inade- quate processing, 46 repetitions (11.56%) were due to inadequate preparation of the patient, and 59 repetitions (14.82 %) were due to other reasons. The number and per- centage of each radiographic repetition fac- tor are represented in Table 2. Discussion Repeated radiographic imaging made up 398 images (8.10%) of 4916 radiograph- ic images totally taken in our study. This amount has been 16.85% in Zewdu et al.’s study13 and 14.1% in Owsue et al.’s study.15 Meanwhile, Yurt et al.’s reported a repeated frequency of 1.2%,14 which is lower com- pared to the current study. When evaluating the repeated images based on the anatomi- cal area in our study along with other stud- ies (Table 3) showed that the repeat rate is higher than the other parts. Pelvis (ranging from 4% to 31.1%) and spinal cord (ranging from 4.6% to 20%) radiographic images seem more likely to be repeated based on previous studies.12-22 Meanwhile our study found the highest rate of repetition in skull radiographic images (13.3%), which was consistent with the previous studies in terms of frequency.13,19,21 This might indicate the need for more training specifically regard- ing these areas.21 In Fintelmann’s12 study, in which only chest radiographs were assessed, repetitions accounted for 13.3% of the images, while in Article Table 1. The number and frequency of evaluated radiographs and the repeats. Radiograph Number (%) Number of repeat (%) Skull 60 (1.2) 8 (13.33) Upper limb 290 (5.9) 30 (10.34) Chest 3060 (62.5) 304 (9.93) Lower limb 472 (9.6) 32 (6.78) Spinal cord 328 (4.64) 14 (6.14) Pelvis 88 (1.79) 2 (2.27) Abdomen 718 (14.61) 8 (1.11) Overall 4916 (100) 398 (8.1) Table 2. Different reasons of repeated radiography. Characteristic The reason for repeated radiography Overall Positioning Patient Exposure Inappropriate Inappropriate image patient Other error movement error processing preparation Radiographs (4916) Skull (60) 2(25) 2(25) 4(50) 0(0) 0(0) 0(0) 8 Upper limb (290) 8(26.67) 6(20) 2(6.67) 0(0) 0(0) 6(20) 30 Chest (3060) 74(24.34) 72(23.68) 34(11.18) 35(11.51) 40(13.16) 49(16.12) 304 Lower limb (472) 4(12.5) 8(25) 10(31.25) 4(12.5) 2(6.25) 4(12.5) 32 Spinal cord (228) 4(28.57) 2(14.29) 4(28.57) 2(14.29) 2(14.29) 0(0) 14 Pelvis (88) 0(0) 0(0) 2(100) 0(0) 0(0) 0(0) 2 Abdomen (718) 2(25) 2(25) 0(0) 2(25) 2(25) 0(0) 8 [page 8] [Healthcare in Low-resource Settings 2023; 11:10575] No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2023; 11:10575] [page 9] our study repetitions accounted for 9.93%. This rate was different from 5.7% to 24% in the previous studies (Table 4).12-22 It is essential to consider that in differ- ent hospitals, the number of repetitions in each anatomic area might be affected by existing specialties, the professionalism of the radiology department assistants.21 Evaluating the causes of image repeti- tion is a very crucial part of studying the imaging repetition. The most common cause of repetition in our study was inap- propriate positioning which was in line with most of the previous studies.12,13,20,21 Earlier studies which evaluated film-based radiog- raphy reported exposure errors as the most common error for leading to repetition.16,20 By reviewing similar papers (Table 2), it can be seen that in most studies, the most prevalent reasons behind repetitive radio- graphs have been related to positioning or inappropriate radiation, which depend on the radiology staff, the hospital being edu- cational, lack of experience for students or new staff, not using tables and radiation fac- tor controllers, the large number of patients, lack of accuracy, inadequate knowledge and experience, application.20,22 These factors are mostly manageable and can be partially corrected by educating staff. In addition, some studies reflect a vari- ation in the reasons for repeated radio- graphs in different regions of a city or dif- ferent hospitals.16,20 In each region, reasons for repetitions in hospitals differed accord- ing to substructures, equipment, staff, the load of work, different departments, and specialties, and thus different percentages have occurred regarding various factors.16,20 Conclusions In this study, the rate of repeated radio- graphs taken in a tertiary hospital was 8.10%, with the most common reason for repetitions being inappropriate positioning. Considering the fact that repetitive radiog- raphy mostly depends on operator-related factors, it is recommended to repeat the study after educating staff in order to com- pare the rate and reason of repetition. References 1. Hofmann B, Rosanowsky TB, Jensen C, Wah KHC. Image rejects in general direct digital radiography. Acta Radiol 2015;4:1–6. 2. Taylor N. The art of rejection: Comparative analysis between comput- ed radiography (CR) and digital radiog- raphy (DR) workstations in the accident & emergency and general radiology departments at a district general hospi- tal using customized and standardized reject criteria over a three year period. Radiography 2015;21:236–41. 3. Atkinson S, Neep M, Starkey D. Reject rate analysis in digital radiography: an Australian emergency imaging depart- ment case study. J Med Radiat Sci 2020;67:72-9. 4. Jones AK, Polman R, Willis CE, Shepard SJ. One year’s results from a server-based system for performing reject analysis and exposure analysis in computed radiography. J Digit Imaging 2011;24:243–55. 5. Lin CS, Chan PC, Huang KH, et al. Guidelines for reducing image retakes of general digital radiography. Adv Mech Eng 2016;8:1–6. 6. Dunn MA, Rogers AT. X-ray film anal- ysis as a quality indicator. Radiography 1998;4:3. 7. Whaley JS, Pressman BD, Wilson JR, et al. 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Radiograph Fintelmann Zewdu Yurt Owusu-Banahene Haghparast Mahmoodi Jadidi Asgharzadeh Atkinson Alashban (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Skull N/A 13.9 3 N/A 11 N/A 13.7 7 14 4.5 Upper limb N/A N/A 8 N/A 3.8 N/A 9.9 4 8 6.7 Chest 13.3 13.7 24 12.5 6.7 N/A 14.6 5.7 7 8.9 Lower limb N/A 15.57 15 12.5 3.7 N/A 11.1 4.3 11 3.8 Spinal cord N/A 20 1 25% 9.3 N/A 17.1 4.6 17.6 10 Pelvis N/A 31.11 9 9 N/A 4 7 23 20 Abdomen N/A 13.2 8 N/A 7 N/A 19.4 2.6 12 13.9 Overall N/A 16.85 1.2 14.1 6 8.7 7.98 4.9 9 9.5 Table 4. The causes of repeated radiographs in different studies. Reasons Fintelmann Zewdu Yurt Owusu-Banahene Haghparast Mahmoodi Jadidi Asgharzadeh Atkinson Alashban (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Positioning error 84.8 N/A 36.11 N/A 24.1 9.3 29.3 N/A 49 41.3 Patient movement 4.6 N/A 16.67 N/A 1.5 14.1 N/A 5.6 5 14.5 Exposure error N/A N/A 1.01 N/A 55.2 6 12.6 49 5 4.4 Inappropriate 1.5 N/A 5.56 N/A 0.4 3.1 2 9.4 1 N/A image processing Inappropriate N/A N/A 15.66 N/A N/A 5.3 N/A N/A N/A N/A patient preparation No n- co mm er cia l u se on ly [page 10] [Healthcare in Low-resource Settings 2023; 11:10575] Riyadh, Saudi Arabia. Global J Qual Safety Healthc 2019;2:30-3. 10. Nol J, Isouard G, Mirecki J. Digital repeat analysis; setup and operation. J Digit Imaging 2006;19:159–66. 11. Zhang M, Chu C. Optimization of the radiological protection of patients undergoing digital radiography. J Digit Imaging 2012;25:196-200. 12. Fintelmann F, Pulli B, Abedi-Tari F, et al. Repeat rates in digital chest radiog- raphy and strategies for improvement. 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Gourabi H, Sharafi A. Evaluation of repeated or abandonment of radiolgra- phy in diagnostic radiology. Partou Journal 2003;1:12-14. [Persian] 19. Jadidi M. Quality assessment of the radiography films. Razi J Med Sci 2002;9:317-326. [Persian] 20. Asgharzadeh AA, Mohseni M. Evaluation of repeated radiographic film and its causes in Kashan hospitals in 2003. Feyz Journal 2005;33:50-56. [Persian] 21. Atkinson S, Neep M, Starkey D. Reject rate analysis in digital radiography: an Australian emergency imaging depart- ment case study. J Med Radiat Sci 2020;67:72-9. 22. Alashban Y, Shubayr N, Alghamdi AA, et al. An assessment of image reject rates for digital radiography in Saudi Arabia: A cross-sectional study. J Radiat Res Appl Sci 2022;15:219-23. Article No n- co mm er cia l u se on ly