This case study is part of a series that describes approaches to true management problems in health systems as a mechanism to share experiences and problem-solving strategies. The authors present the challenges that developed in the Veterans Affairs system after implementation of bar-coded medication administration (BCMA). After reviewing the background to BCMA, discussion of a collaborative breakthrough series (BTS) is explained, a model developed by the Institute for Healthcare Improvement. The case study shares the experiences of the BTS, the positive impact they had on adverse events, and lessons learned that fueled their success. A past study discussed the unintended consequences of BCMA, a past commentary shared its support for widespread implementation, and a case study described an error associated with the new technology.