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."
Because the treatment involved the use of radiation, Karmanos was required by law to file a report with the NRC, WDIV-TV in Detroit reported.
The report registered the incident as a "medical event," which indicates that the institute had problems with its use of radioactive materials, but "does not necessarily result in harm to the patient."
"Because we are committed to the highest quality patient care, we are taking this very seriously," Karmanos announced in a statement. "A thorough internal investigation is under way."