According to the investigation reports, the mix-up originated last summer when an elevator at Duke Health Raleigh was repaired.The inspectors said that workers drained hydraulic fluid from the elevator into about a dozen empty detergent drums that they got earlier at Duke University Hospital when they fixed an elevator there. Most of the drums were marked with the brand name of a detergent used to wash surgical tools. The drums were later picked up and used as if they contained detergent (the detergent and hydraulic fluid have a similar color).
Scary!
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