Objectives: This study explores nurses' use of bar code medication administration (BCMA) technology from a human factors viewpoint. The BCMA technology consists of a medication network server and handheld devices that connect to medication administration record data through wireless radiofrequency link. Methods: A total of 62 observations of medication administration were conducted in 1 academic hospital. Observations were performed by a team of 2 people (a human factors engineer and a

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... t) in a variety of critical care and medical/surgical units. Data were recorded on the medication administration task, the BCMA technology, organizational factors (in particular interruptions), the physical environment, and various individual factors related to the nurses and patients. Results: Eighteen different sequences were identified and represented very large variability in the order in which steps of the medication administration process are performed; some of the sequences can be considered as potentially unsafe acts. We identified various working conditions that can hinder the medication administration process. For example, 20 instances of interruptions were observed. Some patient factors (e.g., isolation patients) were also identified that made the BCMA-based medication administration process challenging. Conclusions: When introducing a new technology into the health care environment, it is important to assess changes in workflow and tasks that may result from the use of the technology. Our study shows the use of direct observation in helping to identify the work system factors that facilitate or hinder the medication administration tasks. This information can help health care organizations identify opportunities to redesign the process and/or the technology to maximize worker efficiency, interaction with the technology, and patient safety.