Residual EO on instruments and supplies can cause serious patient injuries. It is imperative that these items be adequately aerated before they are used. Removing instruments prematurely from an aerator is, indeed, "a blatant disregard for patient safety." The perioperative nurse has the responsibility and accountability for patient protection. Preventive measures and alternatives to using improperly aerated instruments have been described. If these measures do not resolve the problem, the surgery must be postponed until adequately aerated instruments are available.