To address the high incidence of infusion errors, manufacturers have replaced the development of standard infusion pumps with smart pump systems. The implementation and ongoing optimization processes for smart pumps are more complex, as they require larger coordinated efforts with stakeholders throughout the medication process. If improper implementation/optimization processes are followed, hospitals invest in this technology while extracting minimal benefit. We assessed the processes hospitals employed when migrating from standard to smart infusion systems, and the extent to which they leveraged their investments from both a systems and resource perspective. Twenty-nine hospitals in Ontario, Canada, were surveyed that had either implemented smart pump systems or were in the process of implementing, representing a response rate of 69%. Results demonstrated that hospitals purchased smart pumps for reasons other than safety, did not involve a multidisciplinary team during implementation, made little effort to standardize drug concentrations or develop drug libraries and dosing limits, seldom monitored how nurses use the pumps, and failed to ensure wireless connectivity to upgrade protocols and download use data. Consequently, they are failing to realize the safety benefits these systems can provide.