BD Pyxis recallZ-1545-2025 · CareFusion 303, Inc. · initiated Mar 11, 2025
Open, Classified
Is my device affected?
- Compare the model, catalog and lot or serial numbers on your device or its packaging with the code information below. A recall usually covers only specific models or lots.
- If yours is listed, follow the instructions from CareFusion 303, Inc. or your healthcare provider. The company's action is summarized under what the company is doing.
- Do not stop using a prescribed or implanted device on your own — talk to your healthcare provider first.
Where to find your model and lot numbers · What recall classes and statuses mean
Why it was recalled
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.
FDA root cause category: Software design
What the company 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 [email protected] 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
Recall details
- Recall number
- Z-1545-2025
- Status
- Open, Classified
- Initiated by the company
- Mar 11, 2025
- Posted by the FDA
- Apr 9, 2025
- Recalling firm
- CareFusion 303, Inc.
- Quantity
- 7357
- Product code
- BRY
- Distribution
- 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.
Product description
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.
Code information (models, lots, serial numbers)
Show the full code information (6k characters)
REF/UDI-DI(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; 169-137/10885403512544/2.4; 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; 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139070-01/2.4; 139071-01/2.4; 139061-01/2.4; 139066-01/2.4; 139065-01/2.4; 139058-01/2.4; 139060-01/2.4; 139067-01/2.4; 139064-01/2.4; 139059-01/2.4; 139068-01/2.4; 139165-01/2.4; 139069-01/2.4. 1144-00/2.4; 1137-00/2.4; 1147-00/10885403517181/2.4 1145-00/10885403517167/2.4
Devices named in this recall
5 devices in the FDA device registry whose identifier appears in the recall's code information.
- BD Pyxis MEDBANK-TOWERCarefusion 303, Inc. · CABINET, TABLE AND TRAY, ANESTHESIA30 recalls2,581 reports
- BD Pyxis 1145-00Carefusion 303, Inc. · CABINET, TABLE AND TRAY, ANESTHESIA11 recalls1,705 reports
- BD Pyxis 1139-00Carefusion 303, Inc. · CABINET, TABLE AND TRAY, ANESTHESIA12 recalls1,509 reports
- BD Pyxis MEDBANK-MINICarefusion 303, Inc. · CABINET, TABLE AND TRAY, ANESTHESIA14 recalls318 reports
- BD Pyxis 1147-00Carefusion 303, Inc. · CABINET, TABLE AND TRAY, ANESTHESIA10 recalls191 reports
Product lines
Sources and updates
- Recall record: FDA Medical Device Recalls, file dated Oct 16, 2026 · View the FDA recall notice ↗
- Devices: FDA GUDID, file dated Oct 13, 2026. Devices are linked when their identifier (with a valid check digit) appears in the recall's code information.
- Page last rebuilt: Oct 16, 2026. Text above is shown as published by the FDA.
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