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.