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 5000 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 table of the partially turned vial, she assumed the vial contained heparin,1000 units/ml,and with drew 5 ml. it was actually nitroglycerin,5 mg/ml,which she then inadvertently administered (25 mg total) intra - artrially during a procedure.มันเป็นจริงไนโตรกลีเซอ 5 mg / ml .the patient developed severe hypotension but recovered after a brief stay in the ICU