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The following report was received via e-ma … The following report was received via e-mail from the State of Minnesota:</br>Event description: The Minnesota Department of Health was notified on June 15, 2010 at 3:40 p.m. (CDT) of a medical event involving a gamma knife treatment at the University of Minnesota Medical Center - Fairview, University Hospital, Minneapolis. The total treatment consisted of 10 exposures, and was scheduled between 11:30 a.m. and 1:30 p.m. on Tuesday, June 15th.</br>Five automatic positioning system (APS) shots were completed successfully, and then the treatment called for 5 additional trunnion exposures. The first trunnion exposure called for a setting of 76.3, 86.5, 148.1 in the X, Y, and Z directions, respectively. Instead, the settings of 76.3, 86.5, 76.3 were used. In effect, the X setting was inadvertently used for the Z setting. The error was noticed when the coordinates for the second trunnion exposure were being set up. The Z coordinate value used for the first shot was very different from the Z coordinate for next exposure.</br>A new treatment plan was run to determine the dose and the location of the unintended exposure delivery. This plan showed a dose of 3.2 Gy (320 rad) to be delivered to a volume of 0.62 cubic cm at the unintended location. The original plan was re-exported to the GK treatment unit, so the exposure at X, Y, Z setting 76.3, 86.5, 148.1 could be given. Thus, the originally prescribed dose for the treatment region was given. The neurosurgeon and radiation oncologist explained the situation to the patient.</br>Device Manufacturer: Leksell Gamma System</br>Model: 24001 Type C</br>Source Manufacturer: General Electric Company</br>Model: 43047</br>Event Report ID: MN100002</br>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.necessarily result in harm to the patient. +
17:15:00, 15 June 2010 +
46,015 +
15:45:00, 16 June 2010 +
17:15:00, 15 June 2010 +
The following report was received via e-ma … The following report was received via e-mail from the State of Minnesota:</br>Event description: The Minnesota Department of Health was notified on June 15, 2010 at 3:40 p.m. (CDT) of a medical event involving a gamma knife treatment at the University of Minnesota Medical Center - Fairview, University Hospital, Minneapolis. The total treatment consisted of 10 exposures, and was scheduled between 11:30 a.m. and 1:30 p.m. on Tuesday, June 15th.</br>Five automatic positioning system (APS) shots were completed successfully, and then the treatment called for 5 additional trunnion exposures. The first trunnion exposure called for a setting of 76.3, 86.5, 148.1 in the X, Y, and Z directions, respectively. Instead, the settings of 76.3, 86.5, 76.3 were used. In effect, the X setting was inadvertently used for the Z setting. The error was noticed when the coordinates for the second trunnion exposure were being set up. The Z coordinate value used for the first shot was very different from the Z coordinate for next exposure.</br>A new treatment plan was run to determine the dose and the location of the unintended exposure delivery. This plan showed a dose of 3.2 Gy (320 rad) to be delivered to a volume of 0.62 cubic cm at the unintended location. The original plan was re-exported to the GK treatment unit, so the exposure at X, Y, Z setting 76.3, 86.5, 148.1 could be given. Thus, the originally prescribed dose for the treatment region was given. The neurosurgeon and radiation oncologist explained the situation to the patient.</br>Device Manufacturer: Leksell Gamma System</br>Model: 24001 Type C</br>Source Manufacturer: General Electric Company</br>Model: 43047</br>Event Report ID: MN100002</br>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.necessarily result in harm to the patient. +
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00:00:00, 16 June 2010 +
1049-207-27 +
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15:45:00, 16 June 2010 +
0.938 d (22.5 hours, 0.134 weeks, 0.0308 months) +
17:15:00, 15 June 2010 +
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