Abstract: During a busy shift, Employee #1, an OB technician, helped with many crash deliveries and operations. Consequently, surgical instruments and trays that she should have been washing piled up on the sink counter and eventually knocked over a gallon jug of 4 percent formaldehyde. Employee #1 was in and out of the utility room, doing the dishes between surgeries, and noticed that her throat was sore. Toward the end of her shift, she discovered the formaldehyde spill. By the end of her shift, she had difficulty breathing and reported to the emergency room. The next day, her throat had swollen nearly closed. She went to two other clinics that day and the day after. The doctors tried to open her throat with medicine, but it irritated her stomach. Eventually, she saw a toxicologist who put her on medical removal. Seven citations were issued related to the exposure: regulatory T8CCR 5217(e)(7)(c), general T8CCR 5217(e)(8)(b) and 5217(e)(8)(e), serious 5217(g)(1)(d) and 5217(k), and willful regulatory 5217(0)(6)(a), 5217(p)(2)(a), 5217(p)(2)(b), and 17(e)(8)(f).