Post Collimation (Shuttering) Legal Issues, Part 1

In the “legal section” of my presentation I always discussed that at some point I was convinced that someone, somewhere was going to be sued for making a mistake by post collimating pathology off without ever knowing that they had done this.  A couple of years ago a very credible radiographer who works in a good size city in the U.S. (with over a million residents and 5+ large hospitals) came up to me and told me the following story.  Because of the legal implications I had to promise to keep their name and city a secret, but in a 2-3 year period he/she was privy to 2 “lawsuits” that occurred in their city because of post collimation (shuttering).

Both of the “lawsuits” were for different exams but let me give you a perfect example of what happened. Let’s say one of your staff took this lateral C-spine image Fullscreen capture 542010 34127 PM and then post collimated the anterior mandible off but left the marker (this is how we know it was post collimated and usually this style of shuttering is done with CR, not DR).  Months later there is a bone tumor located in the mandible and the patient needs to have major reconstructive surgery.   Afterwards the patient’s attorney requests all of the radiographs the patient has had and they discover that if the mandible had not been post collimated, the tumor would have been discovered half a year earlier and the mandible surgery would very well have been unnecessary.

Both cases were similar to this story.  The reason I wrote “lawsuits” is that neither case went to court, as the imaging department was completely at fault.  Both hospitals gave millions of dollars to the plaintiff, but were able to have everyone involved sign a gag order so that they were unable to tell anyone about the hospitals negligence or how and from where they got the money.  Handing over that money was well worth not having the public find out that the imaging department/hospital made this kind of mistake.

Who knows how many times this has now happened all over the country, but it’s hard to believe it’s only occurred twice and both were in that city.  I firmly believe it’s happened countless times, but every hospital has been able to shut down the bad publicity with lots of money and signed gag orders.  I believe we won’t actually read about this happening until a patient finally decides that they not only believe they can win the case in court and get the money, but want to totally nail the hospital with the horrible publicity at the same time.  Don’t let that hospital be yours!!

Legally your radiologist is responsible to read every bit of anatomy that is radiated and ends up on the Image Receptor (IR).  This means if a chest x-ray is not collimated well and gall stones can be seen and the radiologist misses the stones, they can be liable even though gall stones should not normally show up on a chest image.  This law (like most laws) has not changed one bit from film/screen to digital.

In closing, to use post collimation properly, you must show some pure black or white inside of your post collimated field to prove that you have not cut off any anatomy, whether you believe it’s pertinent or not.

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14 Comments to “Post Collimation (Shuttering) Legal Issues, Part 1”

  1. Kim Schure says:

    Thanks for this article. As a radiographer, just looking at this X-ray I’d agree this collimation is far too tight. Definitely need to open it up! I’ve also taken X-rays where I opened the collimation up slightly if I suspected a fracture higher up or the patient complained of pain slightly outside the collimation field. It’s good to have your training, but we must have common sense and not get so zealous in our collimation we miss something. Likewise we shouldn’t use collimation post processing as a crutch.

    • Hi Kim,
      Thanks for taking the time to comment. I actually didn’t mean that the collimation in the lateral C-Spine was too tight. I’m all for collimating as tight as possible unless it really is a history where you should show more bone length. Otherwise it’s collimate as tight as you can depending on how skilled you are. We’re certainly not saving any radiation if we collimate off a body part and have to repeat the image. You wouldn’t believe how many techs now just leave the collimators wide open and then post collimate afterwards. It’s crazy!!
      Best Regards,
      Dennis

  2. BIJU says:

    Hi , I am radiographer started my career with film radiography with accurate collimation practices and so I can say firstly am not a fan of post collimation process that currently available for CR/DR ( I didn’t understand yet why the DICOM committee allowing the post collimation since it is against the radiation safety and ethics!!)
    In a busy department a radiographer getting only less than two or three minutes to judge a radiograph so better not use post collimation if you opened it slightly more.
    In the above lateral radiograph the anterior part of mandible is cropped ,I hope that area would have been well seen in AP x-ray. Any way a good radiographer skill is still not based on digital cropping it is still on manual collimation before x-ray expose!
    Thanks you
    Biju

    • Hi Biju,

      I agree it is the best practice to take what you got. If you didn’t collimate you’re not supposed to do it after the fact.
      Also remember that the image was lateral C-spine so there wouldn’t really be that much mandible on the AP C-spine if it was done correctly.

      Best Regards,

      Dennis

  3. Gary Holland says:

    Dennis,
    Is there a place that the exact legal wording could be found for not post collimating? Or maybe I should say “not including all radiated anatomy”?

    • Hi Gary,
      I haven’t been able to locate the exact legal wording yet. If I do I will post it on my site. I’m not sure if I understand your “not including all radiated anatomy”.
      Dennis

  4. Olivia says:

    Hi dennis, I’m doing a research proposal on this exact subject and was wondering if you have found any previous literaure or journals on the matter? I’m struggling to find much, as different people use differen terminology for it.

    Thank you.

  5. lois krepcho says:

    please provide some backup for the issue of legal collimation – some official organization or exact law. Thanks

    • Hi Lois,
      A colleague and I have just begun a 4 CME/CEU project on Radiation Safety and we are looking for the exact laws. I’ll write it up wen we locate it.
      Best Regards,
      Dennis

  6. Brenda says:

    I am curious, if you begin to apply post collimation and try to undo this prior to saving. How would you undo the collimation? It’s like there is a small dot showing on the image, but it will not allow you to delete it or send the image without clicking apply collimation. When this is hit the entire image turns black. Is there a way to fix this without having to retake the x ray?

    • Hi Brenda,

      Sorry this has taken me so long to reply to you. I totally forgot to check this page in my website.

      Every vendor is different when it comes to how one does post collimation. I do know that every vendor we have allows us to fix or undo post collimation without having to take another image.

      Sorry I can’t be a bigger help (unless you have our equipment). What vendor are you talking about?

      Dennis

  7. Ron Marker says:

    Dennis,

    I found your article today while searching for articles about collimation and digital imaging and thought I would add to it with the position statement that was voted on and passed at the ASRT House of Delegates meeting this past June.

    Ron

    http://www.asrt.org/docs/default-source/governance/2014-house-of-delegates-minutesdbfbfed00c826490b755ff0000d82291.pdf?sfvrsn=0

    Main Motion C-14.10

    Digital Image Cropping or Masking in Radiography

    It is the position of the American Society of Radiologic Technologists that a digital image should not be cropped or masked such that it eliminates areas of exposure from the image that is presented for interpretation. Pre-exposure collimation of the x-ray beam is necessary to comply with the principle of as low as reasonably achievable (ALARA). To determine that exposed anatomy on an image is not significant or of diagnostic value is a medical decision and is therefore outside of the scope of practice for a radiologic technologist.

    • Hi Ron,

      Sorry this has taken me so long to reply to you. I totally forgot to check this page in my website. I’m so used to emails just coming in to my drs@redshift.com and not having to open up my website. My fault completely though.

      Thanks for the article. They worded it perfectly and I’m going to see if I can add it to my lecture.

      I really appreciate it!!

      Dennis

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