On December 7, 1988, a patient assisting in janitorial duties mixed bleach with phosphoric acid cleaner. Immediately a noxious gas with a strong odor was detected and prompted the evacuation of two wards for 1-1/2 hours. Fire department personnel using self-contained breathing equipment disposed of the chemicals and ventilated the area.
The patient experienced vomiting, cough, and inspiratory discomfort; elevated blood pressure and fever were noted when the patient was treated in the emergency room. Five employees who helped evacuate the ward complained of symptoms including eye irritation and shortness of breath.