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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 40501 | 13 January 2004 05:00:00 | 10 CFR 20.2201(a)(1)(ii) | Two I-125 Seeds Unaccounted for Following Surgery | On 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. |