Abstract: On November 15, 1991, the Holy Cross Medical Center contracted to have the area surrounding the central supply ethylene oxide sterilizer monitored for emissions of ethylene oxide (EtO). An employee operated the sterilizer during the tests. Employees #1 through #11 and two coworkers were exposed to ethylene oxide levels in excess of the permissible exposure limit (PEL). Another coworker exceeded the short term exposure limit (STEL) while changing the EtO cylinder. On November 30, 1991, the employer monitored again with similar results. Employees #1 through #4, #7, #9 through #13, and three coworkers were exposed to levels over the permissible limits. No respiratory protection was worn by any of the employees. The following factors contributed to the EtO levels in the area: 1) the equipment room did not maintain negative pressure; 2) there was no local exhaust over the sterilizer; 3) there was no capture box at the sterilizer drain; 4) ventilation in the equipment room was insufficient; and 5) fugitive emissions were recirculated into the work area.