Bar coding medication administration (BCMA) technology is being widely implemented as a means of preventing medication administration errors, but like many innovations, early experience has yielded both success stories and unintended consequences. This analysis of BCMA implementation at an academic medical center found that potential administration errors were identified by the system, particularly for high-alert medications. However, nurses and pharmacists both engaged in a variety of workarounds that may have compromised the effectiveness of the system. The problem of workarounds has been discussed in prior studies and in an AHRQ WebM&M commentary.