1. Background
In their landmark report, the Institute of Medicine noted
that errors in health care are a significant cause of death
and injury [1]. In response to the national interest to reduce
health care errors, the American College of Obstetricians
and Gynecologists recommended the implementation of
medication practices to improve patient safety [2]. When
implementing change for improvement, there is always the
potential for adverse secondary effects, known as balancing
measures [3]. The Hospital Corporation of America (HCA)
has incorporated many patient safety initiatives including a
conservative standardized oxytocin dosing regimen, part of
which is a standard concentration of 15 units oxytocin per
liter of intravenous fluid [4]. Clark et al. reported improved
maternal and newborn outcomes with the implementation
of the HCA’s oxytocin protocol [5]. Subsequently, many
hospitals including ours adopted a similar protocol in the
interest of improving patient outcomes [6, 7].