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A patient was undergoing a second gamma knife treatment when the treatment was delivered to the wrong side of the brain. The patient and the prescribing physician were informed. The patient received 75 Gy to the brain. No serious effects are expected. The Commonwealth of Massachusetts will be providing an update to this event. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

• * * UPDATE FROM MICHAEL WHALEN TO JOHN SHOEMAKER AT 1350 EDT ON 5/20/13 * * *

The following report was received via email. Event Occurred on 5/17/2013 at approximately 1000 (EDT). With a Gamma Knife Manufacturer: Leksell Gamma System Model: Model 24001 Type C Sealed Sources information: Manufacturer: Elekta Model number: 43685 Prescribed treatment was for one fraction (the daily dose) of 75 Grays to be delivered to the left side of brain. However, the right side of the brain received the treatment. Notified R1DO (Gray) and FSME EVENTS RESOURCE via email.