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ANALISIS PENGULANGAN DAN PENOLAKAN RADIOGRAF

REPEAT & REJECT ANALISIS

WIRA HADI KUSUMA ,STATRO BALI

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Objective

● Mengetahui definisi “analisis reject dan repeat” Program

● Mengidentifikasi tujuan RAP● Mengidentifikasi penyebab

pengulangan dan penolakan film● Melakukan prosedur RAP ● Melakukan perhitungan analisis

RAP

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REJECT ANALISIS●Reject analysis yakni analysis dari foto rontgent yang

ditolak dan diulang karena tidak memenuhi syarat untuk keperluan diagnosa.

●Reject analysis merupakan gambaran secara umum/kasar untuk menemukan penyebab ditolak/diulangnya foto rontgen tersebut, jadi bukan merupakan parameter pasti.

●Sebaiknya menurut Watkinson dan Moores (1983), untuk mendapatkan data yang akurat harus menganalisis secara rinci faktor-faktor yang terkait dengan kualitas radiografi secara keseluruhan.

●Sasaran reject analisis mencakup 2 hal pokok :1.Standardisasi kualitas.2.Mencari penyebab penolakan dan pengulangan

foto.

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QA Radiologi ?

● DOSE● DIAGNOSE

● DUIT● Tujuan utama dalam program Quality Control adalah

menekan jumlah film yang ditolak (rejected) dan diulang (repeated)

● Upaya membatasi terjadinya pengulangan dalam pembuatan radiograf secara nyata akan membatasi bertambahnya radiasi pada pasien

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Reject Analisis Program ?

Metoda yang digunakan oleh Departemen Radiologi untuk menentukan

● Analisis film yang ditolak● Efektivitas biaya● Konsistensi Staff dan equipment dlm

menghasilkan radiograf yang berkualitas

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Tujuan RAP

● Memastikan standar yang tinggi pada teknik radiografi dan pemanfaatan film darat terjamin pada unit radiologi

● Memastikan peralatan radiografi dapat dimanfaatkan secara konsisten dengan standar yang tinggi

● Memastikan bahwa bahan - bahan yang ada digunakan secara efektif (cost effective way)

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lanjutan

● Menyediakan data untuk digunakan dalam menganalisis film yang direject dan aspek-aspek penyebab yang membutuhkan perhatian

● Sebagai perencanaan awal dari QC program

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FAKTOR-FAKTOR PENYEBAB PENGULANGAN DAN PENOLAKAN

● Positioning● Patient motion● Light films● Dark Films● Clear Film● Fog -- Darkroom● Fog -- cassettes● QC● Miscellaneous

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Keterampilan Technologistdlm QC ?

● Kesadaran Technologist sangat penting dlm RAP

● Keterampilan dalam mencegah terjadinya reject dan repeat film

● Kesadaran dlm menekan beban radiasi thd pasien

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Keterampilan yg diperlukan

● Komunikasi yang efektif thd pasien● Immobilisasi● Pembatas sinar (kolimator, diafragma, konus)● Filtrasi● Alat-alat pelindung radiasi● Prosesing radiografi

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● Kombinasi film - intensifying screen● Grid radiografi● Faktor penyinaran● Pengulangan radiograf Penyebab utama -- posisi pasien (55%) penyinaran (34%)

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Menghambat ???

● Determinasi genetis (pengetahuan sebelumnya)

● Determinasi psikis (kebiasaan)● Determinasi lingkungan (kebijakan)

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Prosedur

Lakukan survey terhadap1. Jumlah film yang belum terekspose di ruang prosesing termasuk dlm kaset.2. Jumlah film yang belum terekspose di masing-masing ruang pemeriksaan

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lanjutan

3. Tentukan jumlah dari film yang di reject untuk masing-masing kategori - overexposure

● underexposure● positioning● motion● processing● equipment● miscellaneous (kesalahan yg tdk

teridentifikasi)

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lanjutan

4. Masing-masing ruang mencatat jumlah film yang digunakan dan jumlah film yang ditolak

5. Tim analisis melakukan pengumpulan data dari masing-masing ruang seminggu sekali,

film yang ditolak disortir dan dilakukan kategorisasi

(jika memungkin dilakukan identifikasi tiap pemeriksaan

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Repeated Vs. Rejected RatesContoh;

● Repeated rate : Numbers of film Repeated for patients = X 100 %

All the films used only for patients within period of interest

● Rejected rate :

Numbers of film Rejected not for patients (lost,`QC films. etc) = X 100 % All the films used by the department within period of interest

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Total Repeated/Reject Rate

Rejected films or (+ Repeated films )

= X 100 % Seluruh film yg di pakai oleh department dalam suatu periode waktu tertentu period of interest

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PERHITUNGAN●Jumlah film yang digunakan 1225 lb●Jumlah film yang direject 153 maka angka reject 153 1225 x 100 % = 12,5 %

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●Menentukan reject rate setiap kategori●Jumlah film yang direject 153 lb●Jumlah kasus “too dark” 49 lb

49 153 x 100 % = 32 %

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TEKNIK ANALISIS DATAKarena penelitian ini sifatnya survey, teknik analisis data menggunakan % (prosentase) sebagai berikut :

a. Untuk reject rate = A x 100% A + B + C

b. Untuk Repeat rate = B x 100% A + B + C

(Watkinsons & Moores, 1984)Keterangan : A. jumlah foto yang ditolak

B. jumlah foto yang diulang C. jumlah foto yang baik

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PERHITUNGAN

A. Untuk reject rate = A x 100% A + B + C

B. Reject rate untk masing jenis pemeriksaan : Ae x 100% = A● kepala = 10/40 x100% = 25%●Thorax = 15/40 x 100% = 37,5%●Abdomen = 5/20 x 100% =25%

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W.C. Roentgen

Can we find Mrs. Roentgen's wedding ring?

Sure, it should be between her fingers, I guess!!..

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Siapa yang melakukan ?

● Dilakukan 2 - 3 radiografer (QC technologist)

● Disupervisi oleh senior radiografer (idealnya)

● Didiskusikan dengan radiografer superintendent atau radiologist

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Problem yang ada ??

● Banyak radiografer yang mengartikan bahwa program ini merupakan cheking terhadap mereka

● Sebagai konsekuensi jangan menentukan siapa radiografer yg terbanyak melakukan reject

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● Jika mungkin, upayakan agar setiap radiografer tdk tahu ketika dilakukan pengumpulan data

● Yang terjadi radiografer akan langsung memberikan radiograf ke radiologist atau membuang radiograf yang di reject

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● Setelah melakukan RAP diskusikan hasilnya dengan semua radiografer dan radiologist

● Jelaskan arti hasilnya dan rencana mengurangi angka reject

● Mengingatkan bahwa mengurangi angka reject berarti akan mengurangi radiografer overlooad dan frustasi kerja serta upaya 3 D

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● Menganalisis bersama level radiograf yang diterima radiologist

● Jika radiologist menerima semua radiograf maka film yang direject makin kecil Radiografer kurang perhatian pd pekerjaannya Radiologist kurang peduli dalam menyediakan

data pelayanan medik ke pasien

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QC diperlukan ??

● Meningkatkan kualitas radiograf● Konsistensi

Radiologist membaca radiograf dengan kualitas yang tinggi

merupakan upaya agar Radiografer lebih percaya diri memberikan informasi diagnostik dalam radiograf

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Batasan radiograf yang diterima ??

● Angka reject tidak melebihi 5 %● Idealnya dibawah 2 %

tergantung tidak hanya Program QC yang baik tetapi juga laporan yang ideal diantara radiografer dan radiologist

(pengertiannya ttg radiograf yg berkualitas dan yg hrs direject)

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●Jika total reject rate > 5% maka diharapkan harus melakukan QC program yg terbaik●Jika reject rate 2 % – 5 % maka mungkin berada pada 2 keadaan 1. Kualitas radiograf baik, jika tdk memiliki 1 QC program saat ini maka sebaiknya menginisiatifkan 1 program untuk perbaikan 2. Jika radiologist terbiasa menerima radiograf yang buruk kualitasnya dlm keadaan ini hrs bekerja sama yg baik dng radiologist untuk set up QC program dan menunjukkan dng paket QC ada perbaikan

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SIKLUS RAP

PATIENT

Image

processing

DECISSION

accepted

rej

ec te d

YN

Rejectanalysis

Reject rates

Corrective

Actions

●Reject Analysis (RA) refers to % rejected radiographs

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CONTOH FOTO YANG DITOLAK (REJECT) DAN YANG DITERIMA

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OVER EXPOSURE?

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UNDER EXPOSURE?

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LOW KONTRAS?

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Double Exposure?

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Volume sedikit

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Kabur-gerak?

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KASET TERBALIK

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TERBAKAR

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MOVING GRID-DIAM?

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FIXER TAK SEMPURNA

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TIDAK MERATA DEVELOPER

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RADIOGRAPHIC ARTIFACTS

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TYPES OF ARTIFACTS

PROCESSINGEXPOSUREHANDLING AND STORAGE

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PROCESSING ARTIFACTS● HYPORETENTION● PI-LINES● GUIDE SHOE MARK● STATIC ● ENTRANCE ROLLER MARK● CRINKLE MARK● FINGER MARKS● EMULSION PICK-OFF● WATER STAIN

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EXPOSURE ARTIFACTS●MOTION●IMPROPER POSITIONING●POOR FILM SCREEN CONTACT●DOUBLE EXPOSURE●FOREIGN OBJECTS●BACK-SCATTER●CASSETTE UPSIDE-DOWN●BROKEN CASSETTE●IMPROPER USE OF GRID

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HANDLING & STORAGE ARTIFACTS

LIGHT FOGRADIATION FOGSTATICSCRATCHESHYPORETENTION

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FILMS STUCK TO EACH OTHER DURING PROCESSING

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HYPORETENTION

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PI-LINE

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GUIDE SHOE MARK

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STATIC

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STATIC

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STATIC

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ROLLER MARKS

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FINGER MARKS

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CRIMPING MARK

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CRIMPING MARK

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PICK-OFF

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WATER STAIN

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WATER STAIN

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WATER STAIN

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MOTION

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POOR FILM SCREN CONTACT

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ARTIFACT????

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H.T. (HIGH VOLTAGE) CABLES

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ROTATION + FOG

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ANATOMY OF INTEREST NOT SHOWN

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DOUBLE EXPOSURE

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BACKSCATTER OR CASSETTE UPSIDE-DOWN

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BACKSCATTER

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BACKSCATTER OR CASSETTE UPSIDE-DOWN

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MOIRE EFFECT

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WARPED CASSETTE-LIGHT LEAK

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TWO FILMS IN THE CASSETTEUNDEREXPOSURE

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POWDER

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DEODORANT

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HAIR BUN

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CLOTHES RIBBING

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TUBE

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HAIR STREAKING

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GRID CUT-OFF

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JEWELLERY

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HEARING AID

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LIGHTER IN THE POCKET

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SCATTER FOG

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SANDBAG

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UMBILICAL RING

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AIR IN THE VENTRICLES

AIRHEAD?????

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PLASTER

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DIRT ON THE SCREEN

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PATHOLOGY

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FOGGING

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GRID CUT-OFF

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KYPHOSIS-CHIN

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STRAP

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SCRATCHES

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STATIC

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too dark

correct density

too light

0

The density of the film can be affected by problems in the darkroom, resulting in a film that is too light (below right) or too dark (below left). These changes in film density are discussed in the following five slides.

Film Density

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90°F

95°F

68°F 80°F

Developer too hot

5 minutes development time for all films

If the films are kept in the developer for the correct amount of time but the developer is too hot, the film will get darker as the temperature increases (see below).

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All films processed at 68° F

15 min. 20 min.5 min. 10 min.

Too much time in the developer

If the films are kept in the developer too long, even though the temperature is correct, the film will get darker as the time increases (see below). Notice that the effects are less pronounced with changes in time than they are with a change in temperature as seen on previous slide.

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The completely black area on the right side of the film below is caused by light exposing the film when the darkroom light (not safelight) was inadvertently turned on before the film was completely in the automatic processor. (The tightness of the rollers against the film prevented light from reaching the front part of the film). Opening the door during processing could also create this problem. Light leaks or faulty safelighting would result in an overall darkening of the film, similar to too high a temperature.

Exposure to light

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Dark spots – developer contamination

If drops of developer accidentally contact the film prior to processing, the developing action will start to act on these areas immediately. When the film is then placed in the developer, the overall time that these areas are developed is longer than for the rest of the film, resulting in darker spots.

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Light spots – fixer contamination

If drops of fixer accidentally contact the film prior to processing, the fixing action will start to act on these areas immediately. When the film is then placed in the developer, there are fewer crystals to be converted to black metallic silver, resulting in lighter spots. Usually the contamination is on one side of the film only so that the crystals in the emulsion on the opposite side are processed normally and you can still see part of the image.

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Yellow/brown stain – depleted fixer

If the film is not adequately fixed, the undeveloped crystals (those without exposure centers) will not be removed from the film, resulting in a yellowish-brown stain. This is more apparent in the film below in the areas that were not exposed to x-rays. The left side of the film represents a cone cut (dotted lines) and the areas in the crowns represent amalgam or gold restorations.

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Films overlapped during processing

0

If films are fed into the automatic processor too quickly, the films may overlap each other, preventing the processing chemicals from acting on the overlapped emulsions. This results in a dark area on each film (see below).

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Dark lines

If the automatic processor is not cleaned properly, the rollers may become dirty . This results in black lines on the film (see below).

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Static electricityIf the film is removed too quickly from the packet

(intraoral) or from the film box or cassette (extraoral), contact with overlying materials may create friction, resulting in a static discharge. This may create black dots, lines, “lightning bolts”, or tree-branch patterns (see below).

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TUGAS KELOMPOK●Cari dasar reject film menurut kemenkes●Cari faktor-faktor penyebab reject film dalam 1 bulan●Analisa dg EXCEL (grafik & regresi linier)●Ganjil (manual) atau Genap (automatic)

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TUGAS KELOMPOK●Apa yang dimaksud dibawah ini & berikan contohnya:

Age Fog, Light Fog, Radiation Fog, Oxygen Fog, Chemical Fog, Back Scatter Fog, Dechroic Fog, Artefact, Yellow Patch, Reticulation, Frilling, Light Patch dan Film terbakar


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