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RecallWatchMedical Device Safety
Class IIOngoingZ-1545-2025

CareFusion 303, Inc. recalls BD Pyxis" MedBank" Mini and BD Pyxis" MedBank" Tower

CareFusion 303, Inc.San Diego, CA, United StatesReported Apr 16, 2025 · 1 year ago
Legal News Analyst ·

Reason for recall

Due to a software bug, automated dispensing cabinet is unable to calculate countback discrepancies during the issue process, which causes incorrect transaction quantity to be recorded. This bug can also result in the CUBIE opening more times than needed for the transaction to be completed, which may result in a patient receiving more than the intended dose of medication.

Affected product

Check your device

Enter a lot, serial, REF, or UDI number from your device's label to check it against this recall's listed codes.

BD Pyxis" MedBank" Mini and BD Pyxis" MedBank" Tower, BD Pyxis" MedFlex, BD Pyxis" MedBank" MedPass are automated dispensing cabinets (ADC) intended to securely store and dispense medications to a qualified and authorized user in a clinical settings.

Lot / code information

GTIN
)/Software Version: 169-143/10885403512568/2.4; 169-145/10885403512568/2.4; 169-144/10885403512568/2.4; 169-142/10885403512568/2.4; 139088-01/1.2.3.23; 155288-01/10885403508721/2.4; 169-137/1088540351…Show all
)/Software Version: 169-143/10885403512568/2.4; 169-145/10885403512568/2.4; 169-144/10885403512568/2.4; 169-142/10885403512568/2.4; 139088-01/1.2.3.23; 155288-01/10885403508721/2.4; 169-137/10885403512544/2.4; 155311-01/10885403510847/2.4; 169-151/10885403512544/1.2.3.23; 138921-01/2.4; 155159-01/10885403504655/2.4; 169-101/10885403512544/2.4; 139122-01/2.4; 155160-01/10885403504662/2.4; 169-102/10885403512544/2.4; 138912-01/2.4; 155161-01/10885403504679/2.4; 169-103/10885403512544/2.4; 138902-01/2.4; 169-104/10885403512544/2.4; 138903-01/2.4; 155163-01/10885403504686/2.4; 169-105/10885403512544/2.4; 138908-01/2.4; 169-106/10885403512544/2.4; 138906-01/2.4; 155165-01/10885403504693/2.4; 169-107/10885403512544/2.4; 169-152/10885403512544/1.2.3.23; 138907-01/2.4; 155166-01/10885403504570/2.4; 169-108/10885403512544/2.4; 139131-01/2.4; 155167-01/10885403504587/2.4; 169-109/10885403512544/2.4; 139091-01/2.4; 155168-01/10885403504594/2.4; 169-110/10885403512544/2.4; 138909-01/2.4; 155169-01/10885403504600/2.4; 169-111/10885403512544/2.4; 138910-01/2.4; 155310-01/10885403510830/2.4; 169-112/10885403512544/2.4; 169-150/10885403512544/1.2.3.23; 138915-01/2.4; 155171-01/10885403504617/2.4; 169-113/10885403512544/2.4; 138943-01/2.4; 155081-01/10885403503870/2.4; 169-23/10885403512568/2.4; 138955-01/2.4; 155082-01/10885403503887/2.4; 169-24/10885403512568/2.4; 138924-01/2.4; 155083-01/10885403503894/2.4; 169-25/10885403512568/2.4; 138960-01/2.4; 155084-01/10885403503900/2.4; 169-26/10885403512568/2.4; 138961-01/2.4; 155085-01/10885403503917/2.4; 169-27/10885403512568/2.4; 138926-01/2.4; 155086-01/10885403503726/2.4; 169-28/10885403512568/2.4; 138927-01/2.4; 155087-01/10885403503733/2.4; 169-29/10885403512568/2.4; 155293-01/10885403509926/2.4; 169-138/10885403512568/2.4; 155303-01/10885403510779/2.4; 139082-01/2.4; 155088-01/10885403503740/2.4; 169-30/10885403512568/2.4; 155305-01/10885403510793/2.4; 139056-01/2.4; 155089-01/10885403503757/2.4; 169-31/10885403512568/2.4; 155304-01/10885403510786/2.4; 139045-01/2.4; 155090-01/10885403503764/2.4; 169-32/10885403512568/2.4; 138932-01/2.4; 155091-01/10885403503771/2.4; 169-33/10885403512568/2.4; 139084-01/2.4; 155092-01/10885403503788/2.4; 169-34/10885403512568/2.4; 138963-01/2.4; 155093-01/10885403503795/2.4; 169-35/10885403512568/2.4; 155294-01/10885403509933/2.4; 169-139/10885403512568/2.4; 138938-01/2.4; 155094-01/10885403503801/2.4; 169-36/10885403512568/2.4; 139125-01/2.4; 155095-01/10885403503818/2.4; 169-37/10885403512568/2.4; 138919-01/2.4; 155096-01/10885403503696/2.4; 169-38/10885403512568/2.4; 139126-01/2.4; 155097-01/10885403504198/2.4; 169-39/10885403512568/2.4; 139127-01/2.4; 155098-01/10885403503702/2.4; 169-40/10885403512568/2.4; 139043-01/2.4; 155099-01/10885403504204/2.4; 169-41/10885403512568/2.4; 138933-01/2.4; 155100-01/10885403504211/2.4; 169-42/10885403512568/2.4; 155299-01/10885403510526/2.4; 169-140/10885403512568/1.2.3.23; 139142-01/2.4; 155101-01/10885403504228/2.4; 169-43/10885403512568/2.4; 155302-01/10885403510762/2.4; 138959-01/2.4; 155102-01/10885403504235/2.4; 169-44/10885403512568/2.4; 138954-01/2.4; 155103-01/10885403504242/2.4; 169-45/10885403512568/2.4; 138934-01/2.4; 155104-01/10885403504259/2.4; 169-46/10885403512568/2.4; 138950-01/2.4; 155105-01/10885403503719/2.4; 169-47/10885403512568/2.4; 138947-01/2.4; 155106-01/10885403504266/2.4; 169-48/10885403512568/2.4; 138945-01/2.4; 155107-01/10885403504273/2.4; 169-49/10885403512568/2.4; 138931-01/2.4; 155108-01/10885403504280/2.4; 169-50/10885403512568/2.4; 138929-01/2.4; 155109-01/10885403504327/2.4; 169-51/10885403512568/2.4; 138946-01/2.4; 155110-01/10885403504297/2.4; 169-52/10885403512568/2.4; 138940-01/2.4; 155111-01/10885403504303/2.4; 169-53/10885403512568/2.4; 138952-01/2.4; 155112-01/10885403504099/2.4; 169-54/10885403512568/2.4; 138917-01/2.4; 155113-01/10885403504105/2.4; 169-55/10885403512568/2.4; 138918-01/2.4; 155114-01/10885403504112/2.4; 169-56/10885403512568/2.4; 138941-01/2.4; 155115-01/10885403504129/2.4; 169-57/10885403512568/2.4; 138905-01/2.4; 155116-01/10885403504136/2.4; 169-58/10885403512568/2.4; 138916-01/2.4; 155117-01/10885403504143/2.4; 169-59/10885403512568/2.4; 139141-01/2.4; 155118-01/10885403504150/2.4; 169-60/10885403512568/2.4; 138914-01/2.4; 155119-01/10885403504334/2.4; 169-61/10885403512568/2.4; 139063-01/2.4; 155120-01/10885403504167/2.4; 169-62/10885403512568/2.4; 138953-01/2.4; 155121-01/10885403504174/2.4; 169-63/10885403512568/2.4; 138936-01/2.4; 155122-01/10885403504181/2.4; 169-64/10885403512568/2.4; 138962-01/2.4; 155123-01/10885403504082/2.4; 169-65/10885403512568/2.4; 138944-01/2.4; 155124-01/10885403504075/2.4; 169-66/10885403512568/2.4; 138957-01/2.4; 155125-01/10885403503658/2.4; 169-67/10885403512568/2.4; 138922-01/2.4; 155126-01/10885403503665/2.4; 169-68/10885403512568/2.4; 138930-01/2.4; 155127-01/10885403503672/2.4; 169-69/10885403512568/2.4; 139128-01/2.4; 155128-01/10885403503689/2.4; 169-70/10885403512568/2.4; 138958-01/2.4; 155129-01/10885403504341/2.4; 169-71/10885403512568/2.4; 138920-01/2.4; 155130-01/10885403504358/2.4; 169-72/10885403512568/2.4; 138937-01/2.4; 155131-01/10885403504365/2.4; 169-73/10885403512568/2.4; 139086-01/2.4; 155132-01/10885403504372/2.4; 169-74/10885403512568/2.4; 138942-01/2.4; 155133-01/10885403503542/2.4; 169-75/10885403512568/2.4; 138949-01/2.4; 155134-01/10885403503559/2.4; 169-76/10885403512568/2.4; 139062-01/2.4; 155135-01/10885403503566/2.4; 169-77/10885403512568/2.4; 138939-01/2.4; 155136-01/10885403503573/2.4; 169-78/10885403512568/2.4; 138948-01/2.4; 155137-01/10885403503597/2.4; 169-79/10885403512568/2.4; 138956-01/2.4; 155138-01/10885403503603/2.4; 169-80/10885403512568/2.4; 138923-01/2.4; 155139-01/10885403503610/2.4; 169-81/10885403512568/2.4; 139163-01/2.4. 1119-00/10885403512704/2.4; 1139-00/10885403512704/2.4. 139054-01/2.4; 139055-01/2.4; 139053-01/2.4; 139041-01/2.4; 139046-01/2.4; 139038-01/2.4; 139040-01/2.4; 139049-01/2.4; 139044-01/2.4; 139039-01/2.4; 13 …

What the firm is doing

On 3/11/2025, "URGENT MEDICAL DEVICE CORRECTION" notices were mailed and emailed to Medical Director, Risk Manager, Medical Device Safety Officer, Lab Manager, Clinical Engineering, and other customers asking them to take the following actions: 1) Best practice is to verify the total dose being removed is accurate against the provider's order, and if available utilize barcode medication administration as an additional check to ensure the correct dose is retrieved prior to administration. 2) Customers can inventory the CUBIE pocket via a cycle count or blind count to correct the inventory when discrepancies occur. Customers can refer to the BD Pyxis MedBank Cabinet User Guide - 10000414987 Ver. 01, Version v2.4 for instructions. Refer to chapter six (6), page 103. 3)Customers should ensure backup procedures (which may include but are not limited to keys, emergency medication supplies, alternate devices in proximity, etc) are in place and staff have all been properly educated on them. 4) Share this letter with any facilities within your network that you may have distributed affected devices to. 5) Post this Recall Letter on or near affected products as a reminder of the recall and the steps/instructions that are needed to be followed. 6) Complete and return the Response Form via email to bdrc44@bd.com Firm is in the process of contacting all customers to schedule an appropriate time for the software upgrade to MedBank software version 1.7. If you require further assistance, contact the firm's technical support: 1-866-930-9251 Phone Hours: 24 hours, 7 days a week Website: https://bdx.my.site.com/CC360/s/impactedproducts?rn=MMS-24-5163/MMS-25-5183/5184

DistributionShow details

US Nationwide distribution: CA, TX, WI, CO, AK, VA, TN, WA, NC, NY, MS, FL, KS, MI, IN, MN, MT, KY, MO, UT, NJ, OH, PA, ND, OR, NE, SD, NV, OK, GA, MA, IA, HI, ME, AZ, IL, SC, LA, WV, AL, ID, NM, DC, NH, VT, CT, MD, AR, WY.

Class IIWhat this means

Use of the product may cause temporary or medically reversible adverse health consequences.

Sources & references

Source: U.S. FDA openFDA device enforcement reports. This summary is informational and may lag or differ from the official record. Always verify against the FDA before acting.

Taylor Coteus
Legal News Analyst

Taylor Coteus is RecallWatch's Legal News Analyst, covering FDA medical-device enforcement and patient-safety litigation. He reviews every recall against the FDA's official openFDA record before it is published and is responsible for corrections and editorial accuracy.

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