The Recall Desk
HighFDA (Devices)·Z-0671-2025·Announced 2024-12-18

Automated Dispensing Cabinet Software Flaw May Cause Medication Dispensing Errors

The BD Pyxis MedStation ES automated dispensing cabinet may dispense the wrong medication due to a software issue, potentially causing medication errors and inventory shortages.

What this means for you

Real risk of harm even if no illness or injury has been reported yet. Stop using the product and follow the agency's guidance.

Our severity reasoning: This is an FDA Class II recall involving potential medication dispensing errors due to software defects. No illnesses, injuries, or deaths are reported in the source text. Per the severity rubric, risk-of-harm products where injury has not yet been reported score as High (3).

Plain-English summary

The BD Pyxis MedStation ES 7 Drawer Auxiliary Tower is an automated medication dispensing cabinet used in healthcare facilities. A software defect affecting this device has been recalled.

Due to a software issue, the cabinet may open the wrong storage pocket or position. This can result in unintended removal of incorrect medications or allow a different medication to be accidentally loaded into the system, potentially leading to inventory shortages or medication stockouts.

Approximately 40,763 units are affected by this recall with worldwide distribution, including facilities across the United States and multiple countries. Healthcare providers using these devices should contact the manufacturer for guidance.

Facilities should review their medication management procedures and consider this software issue's risk of medication dispensing errors pending a fix or replacement from the manufacturer.

The recalled product

Product
BD Pyxis MedStation ES 7 Drawer Auxiliary Tower, REF: 324
Manufacturer
CareFusion 303, Inc.
Hazard
  • medication-error
  • dispensing-error
  • inventory-depletion

Distribution

Distributed nationwide across the United States.