Abstract: At approximately 8:30 a.m. on November 11, 1995, a hospital pharmacy technician was in the pharmacy storage room helping Employee #1, a delivery driver from Baxter Health Care, load a freezer with frozen antibiotics. Other hospital employees were sorting medication and cleaning up. The pharmacy technician determined that the pharmacy secretary, who was helping in the cleanup by pouring expired medication down the sink, had poured a half pint of an 89 percent phenol solution down the sink. Other chemicals that went down the sink include aluminum hydroxide, Alupent syrup, albuterol syrup, 3 percent hydrogen peroxide, Riopan, Neomycin, and Actifed. Some of the employees smelled phenol. Employees were evacuated and the fire department responded. Employees were sent to the hospital. Employee #1 indicated that he had a headache and trouble breathing. The doctor's first report indicates cenhalgia, a inhalation injury, and first- and possibly second-degree burns to the face. Major factors contributing to accident were that the pharmacy secretary was never trained to handle hazardous substances; the task was not routine; and there were no supervisory personnel present to evaluate and prevent this incident.