Oxytocin as a "high alert medication": a multilayered challenge to the status quo.

Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes. In 2007 it was added to the Institute for Safe Medication Practices short list of medications "bearing a heightened risk of harm," which may "require special safeguards to reduce the risk of error." In January 2009 the American Journal of Obstetrics and Gynecology published a Clinical Opinion paper about oxytocin's inclusion on the list and how the obstetrics profession in the United States should respond. The authors call for the development of specific evidence-based guidelines to reduce the likelihood of patient harm by limiting elective use of oxytocin, decreasing the need for indicated use, reducing dosages during necessary use, giving more responsibility and authority for the patient's safety to the professional who is "at the bedside administering and monitoring the oxytocin infusion" (i.e., the nurse), and accepting that "more time rather than more oxytocin is generally preferable" once adequate uterine activity has been achieved. It is unfortunate that this important paper discounted the risk of harm from cesarean sections and did not mention the strong linkage between epidural analgesia and use of oxytocin. Physicians, midwives, nurses, and others should examine and discuss these issues further in view of increased alertness to the risk of harm from unsafe use of oxytocin.