A performance improvement process to tackle tachysystole.

Inappropriate use of oxytocin is an important patient safety issue. In this article, the authors describe success in "tackling tachysystole" using an evidence-based algorithm for oxytocin administration. Monthly audits (N = 1160) reached 100% compliance. An algorithm posted at the bedside, multidisciplinary follow-up, education, and widely disseminated results helped counter resistance and normalization of deviance. Clinicians need standardized definitions and guidelines with measures of progress to manage safety concerns such as tachysystole.