Abstract: Between 12:00 a.m. and 1:00 a.m. on April 13, 2007, Employee #1, a janitorial employee of the hospital, was using Neutral Quat Disinfectant Cleaner 23 to clean operating room equipment in an operating room. He began to have breathing problems. He used his inhaler but it did not work. He saw another employee and asked for help, then collapsed and had a seizure. The reaction was probably due to asthma aggravated by chemical exposure. He was taken to the emergency department and was admitted for treatment. He was hospitalized for more than 24 hours and was discharged on April 15, 2007. He was released to full work duty on April 23, 2007.