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 Start dateReporting criterionTitleEvent descriptionSystemLER
ENS 4050113 January 2004 05:00:0010 CFR 20.2201(a)(1)(ii)Two I-125 Seeds Unaccounted for Following SurgeryOn 1/13/04 a male patient received I-125 implants. Following the operation, the physician did not properly inventory the residual I-125 seeds. Two (2) seeds were missing (0.36 millicuries/ea). St. Josephs Wayne Hospital was informed of the discrepancy by the physician performing the operation and conducted extensive surveys with negative results. Corrective action includes an administrative requirement to have either a dosimetrist or physicist present during all future implant operations to ensure adequate inventory control.