DETROIT — A patient undergoing treatment at the Karmanos Cancer Institute in Detroit received a dose of radiation on the wrong side of the brain, according to a report filed with the United States Nuclear Regulatory Commission.
According to the report, a crucial piece of information was misread prior to treatment with a gamma knife, which delivers a targeted form of radiation therapy that zeros in on specific locations in the brain.
The patient went through a routine MRI (magnetic resonance imaging) scan of the brain just before the procedure, but went into the scanner “feet first,” rather than the standard practice of head first, the document said.
“The gamma knife-authorized medical physicist failed to recognize the scanning error when importing the MRI images into the Gamma Knife treatment planning computer, and subsequently registered them as head first,” the report said. “This resulted in the wrong side of the patient being targeted and treated.”
What went wrong? Deviation from standards (if there are standards)? Too-busy doctors? I’ll be interested to see who gets the blame.