Publications

Abstract not provided.

A mercury-based sphygmomanometer was used in the New Mexico Tech Medical clinic because a patient had consistently high blood pressure measurements when a mercury-free sphygmomanometer was used. The mercury-based unit was chosen to verify the mercury-free measurements. When the nurse began pumping up the cuff, mercury leaked from the bottom of the machine. Prior to that use, the sphygmomanometer functioned correctly, and inspection showed no visible cracks. Knowing that mercury (Hg) was hazardous to patients, that it vaporized at room temperature, and that the clinic had no windows, the nurse moved the sphygmomanometer from the clinic to a nearby biohazard room. In addition, the nurse taped the door gaps on the outside of the biohazard room to limit exposure. The biohazard room was vented to the outside, but that fact was not commonly known by the incident response team. The floor between the clinic and biohazard room was carpeted, resulting in Hg contamination of the carpet as well as the clinic and the biohazard room.

NM Institute of Mining and Technology, NM Tech, reached out to Sandia National Laboratories to perform a causal analysis resulting in lessons learned for a mercury spill on campus earlier in the academic year. That causal analysis meeting was held on October 30, 2018 on the NM Tech campus and this report is a result of interviews and information gathered prior to, during, and after that meeting.