Quality of chest x-rays


Audit to assess the diagnostic quality of chest x-rays.

This audit could be the initial step of a quality improvement project in improving the diagnostic quality of chest x-rays.


Antero-posterior (AP) chest x-rays are suboptimal for diagnosis compared with a well inspired postero-anterior (PA) chest x-ray. It is preferable to perform a PA chest x-ray whenever possible. In the author's observation, experienced radiographers are often promoted to CT, Ultrasound and MRI removing radiographic skills from the chest x-ray rooms and newly qualified radiographers may be unaware that AP chest x-rays are suboptimal for diagnosis.

The Cycle

The standard: 

• Every effort should be made to perform a PA erect chest x-ray

• The Standard will vary between different patient referral groups - i.e. in-patient (IP), General Practice (GP), out-patient (OP) or Emergency department (ED) referral

• Suggested targets are indicated below but should be agreed locally


75% PA erect for IP and ED patients

95% PA erect for OP and GP patients

Assess local practice


Measure the number of chest x-rays performed AP and PA

Measure each patient group separately

Data items to be collected: 

• Suggest perform two 24 hour audits per month

• Include both chest x-rays performed in 'office hours' and 'out-of-hours'

• Suggest a random assessment without looking at rotas so that there is no bias (as to the radiographers on duty) during the audit

For each CXR:

1. Each chest x-ray is checked whether it is an AP or PA using RIS and PACS

2. The time the chest x-ray was performed

3. Radiographer who has taken the chest x-ray - this may be kept confidential

4. Mode of transport of the patient, e.g. walking, chair or trolley

Suggested number: 

Include all chest x-rays performed within the audit time period for each patient group

Exclude portable and paediatric chest x-rays

Suggestions for change if target not met: 

• Project lead to present results at radiographer staff meeting, with department managers in attendance

• Announce regular 24 hour audits of AP vs PA ratio

• Reminders to staff as to the diagnostic importance of PA images

• Confidential discussion with individual radiographers if they are a consistent outlier

• Appoint a lead radiographer to regularly update staff, and help train newly qualified staff

• Display posters in staff areas emphasising the importance of PA vs AP, and the performance against the target

• Suggest purchase positioning aids if not available.  If available encourage its use

• The radiographers should be encouraged to record specific issues and suggestions

• The radiologist may give a talk to radiographers emphasising the diagnostic importance of good chest x-rays

• Re-audit in 6 months after all staff have been made aware of the results and the suggestions for improvement have been implemented


Lead radiographer time (6-8 hours)

Radiologist time 2-4 hours

PACS and RIS to retrieve and review chest x-rays

  1. ACR Practice guideline for the Performance of Paediatric and Adult Chest Radiography. ACR 2014  http://www.acr.org/~/media/B40302EE286D4120AAEDE44B409DD45E.pdf

  2. EUR 16260 - European Guidelines on Quality Criteria for Diagnostic Radiographic Images. European Commission (1996).

Editor's comments: 

These standards were derived locally and are dependant on patient mix. In a department with a very high proportion of non ambulant patients they may not be achievable and should be adjusted accordingly. For example in the ED a PA chest x-ray in 100% of walking patients, 80% of chair patients and 10% of trolley patients may be more appropriate. Once an indvidual department's achievable standard is determined this can then be monitored to ensure the standard is maintained.

Geida Taylor-Rowlands
Susan King
Gavin Stoddart
Published Date: 
Thursday 28 January 2016

Last Reviewed: 
Friday 9 February 2018