A nurse preceptor had set up a table in a cardiac catheterization lab with drugs for use during the procedure. Indicating to a nurse being oriented to the lab that a heparin vial was on the table, she ask the other nurse to draw up 5,000 units of heparin.
The in experienced nurse didn’t know that a vial of nitroglycerin was on the table as well. ( small amounts are sometime used during cardiac catheterization to reduce arterial spasm. ) Seeing “rin” from the end of the drug name on the label of the partially turned vial, She assumed the vial contained heparin , 1,000 units/ml, and with drew 5 ml. It was actually nitroglycerin, 5 mg/ml , which she then inadvertently administered ( 25 mg total ) intra-arterially during a procedure. The patient developed severe hypotension but recovered after a brief stay in the ICU