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Reject and repeat analysis is an integral aspect of quality assurance programs for medical imaging departments across the globe as it guides staff training, equipment set-up and department workflow. Rejected and repeated images represent unnecessary patient radiation exposure, inadequate imaging techniques and an increase in departmental expenses. The approach to reject analysis has significantly changed as technologies have improved but reject rates and their reasoning have not always reflected the technological advances. With students and junior radiographers entering a predominantly digital workplace it is crucial that attention is brought to the need to reduce reject and repeat rates with DR. All radiographers should be aware of image quality standards, the benefits of post-processing, understand the need to continuously assess exposure index values, and adhere to the ‘As Low As Reasonably Achievable’ (ALARA) principal. This systematic review of evidence-based research articles aims to compare and critically evaluate the methodologies and results of general x-ray reject analysis of conventional film-screen, computed and digital radiography, in order to determine the most effective approach of reject analysis and the effect that digital radiography has had on reject rates.