This cross-sectional observational study discovered a number of unintended consequences of bar code medication administration (BCMA) technology implementation and the potential for new paths to adverse drug events. Using ethnographic observation techniques on nearly 70 nurse-BCMA interactions, investigators identified and discuss five negative side effects of the new medication process. Both conceptual and operational frameworks are presented, but the authors point out that their findings do not call for abandoning the technology. They argue that, with implementation of any new technology, redesign and anticipation of unintended effects must be considered. The technique of observation described in this study may serve as a very useful tool for similar technology advances and implementation.