From October 1987 through November 1989, five episodes of chlorine gas exposure with toxicity to at least 14 persons occurred at two state hospitals in California. Each hospital provides inpatient treatment to approximately 1000 forensic psychiatric patients. As part of their rehabilitation programs, selected patients perform cleaning duties under the supervision of janitors or nursing staff. Each incident occurred during the performance of these duties and involved the mixture of bleach (sodium hypochlorite) and a phosphoric acid cleaner by inpatients. This mixture produced chlorine gas and other chemical byproducts (Figure 1a and 1b) and resulted in temporary illness in exposed persons.