Nurse leaders are challenged to stay abreast of the unintended consequences of safety technology. Many hospitals have adopted smart pumps to improve medication safety. Unfortunately, this technology has limitations. Despite their success in averting some errors, lethal outcomes are still reported in organizations using smart pumps. Documented workarounds, such as bypassing safety features, threaten patient safety. This concerning information has prompted leaders to evaluate current implementation strategies. This article provides an overview of smart pumps, highlights the Institute for Safe Medication Practices' implementation guidelines, and presents a case report of the use of smart pump data to improve clinical practice.