[Discription of Incident]
The victim suffered from poisoning
by inhaling residual ethylene oxide gas in a sterilization chamber during
the work to sterilize beds, etc., by using the sterilization and drying
equipment in a hospital.
The victim went to
work around 7:00 a.m., removed sterilized items from the chamber in
sterilization and drying equipment, set new items to be sterilized in the
chamber, closed the chamber door, opened a gas value, and turn on a switch
to start the operation. This sterilization and drying equipment started
automatic operations with settings of eight hours for the sterilization
process and six hours for discharge of residual gas after the
process.
Around 5:00 p.m.,
the victim went to the sterilization room to start sterilization work for
the next items. At that time, one hour had passed after the equipment was
switched to residual gas discharge operations.
Because the victim
believed that manually stopping the equipment during the residual gas
discharge process can discharge ethylene oxide gas more quickly than under
automatic operations, the victim opened the operating panel and turned off
the exhaust timer switch. As this stopped the ventilation fan and overall
equipment operations, the victim opened the chamber and started to replace
the items to be sterilized, during which the victim inhaled residual
ethylene oxide gas.
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