Objective. To determine if there was an increase in postpartum (PP) hemorrhage after decreasing the PP oxytocin dose from 40 to 30 units. Study Design. Retrospective cohort study comparing 8 months before to 8 months after the change. PP day 1 hemoglobin was subtracted from admission hemoglobin. Mean change was compared by Student’s -test. The best fit polynomial was analyzed for trends between the two time frames. Women who received blood transfusions were excluded. Results. 73/3564 (2.0%) women received blood transfusions in the pre group and 64/3295 (1.9%) women in the post group, . Mean hemoglobin change ± standard deviation was ？g/dL for pre versus ？g/dL for post, . 1003/3114 (32.2%) in the pre group had a hemoglobin decrease of ≥2？g/dL compared to 918/2895 (31.7%) in the post group, . 261/3114 (8.4%) in the pre group had a hemoglobin decrease of ≥3？g/dL compared to 252/2895 (8.7%), . There were no significant trends between the two time frames. Conclusion. The change in the dose of PP oxytocin did not result in an increase in postpartum hemorrhage or an increase in the need for blood transfusion. 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]. In the past our labor and delivery unit had prepared oxytocin at a concentration of 20 units/L. With this concentration, the displayed rate on the infusion pump did not numerically match the dose of oxytocin that was being infused. For every 3.0？mL/hr of infusion, only 1.0 milliunit of oxytocin was infused per minute. This was thought to be ambiguous and a potential source for medication errors. Therefore our unit changed the oxytocin concentration as part of the HCA’s standardized
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