OBJECTIVES: Intravenous patient-controlled analgesia (IV PCA) is widely used for postoperative pain management. The objectives of this pilot observational study were to define the tasks and personnel required for IV PCA administration and to identify problems arising with use of this modality. METHODS: This study was conducted at a single site academic medical center in Philadelphia, PA, USA. Process flow diagrams were developed based on interviews and observations conducted in the central supply, biomedical engineering, pharmacy, and nursing departments. The diagrams mapped all steps in the process of IV PCA administration within each department. Problems related to IV PCA administration were also recorded. RESULTS: Forty-two patients who underwent hip replacement surgery were selected for observation. Central supply collected, cleaned, and delivered IV PCA pumps to appropriate locations, and delivered malfunctioning pumps to biomedical engineering. Biomedical engineering evaluated malfunctioning pumps and performed routine maintenance on all pumps. Pharmacy prepared IV PCA syringes and delivered them to the nursing units. Nursing staff processed IV PCA orders, obtained pumps and set them up, redressed or restarted IV lines, educated patients, discontinued PCA, and completed the necessary documentation. Thirty-seven of 42 (88%) patients experienced at least one IV PCA-related problem, with an average of 3.3 problems per patient. The most common problems were drug-related (79%), including dose adjustments, syringe replacement, and medication changes. Patient-related problems were also common (45%), and included the need for patient re-education regarding IV PCA use, assisting patients in using the on-demand button, and addressing side effects related to opioid use. IV PCA line problems and pump-related problems were observed in 14% and 12% of patients, respectively. CONCLUSIONS: IV PCA administration requires a complex series of processes and coordination among several hospital departments. Problems with IV PCA are common and require staff time and effort to resolve.