The Recall Desk
HighFDA (Devices)·Z-2498-2024·Announced 2024-08-14

Automated Dispensing Cabinet Software Error May Print Incorrect Medication Bin Labels

CareFusion's BD PYXIS MEDBANK automated dispensing cabinet contains a software flaw that may print incorrect medication bin labels, potentially leading to dispensing of wrong medications.

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: FDA Class II recall involving a software defect in a medication dispensing system that could lead to incorrect medication administration. The hazard is described as 'potential' with no reported illnesses or injuries, making this a theoretical risk-of-harm scenario rather than an acute crisis.

Plain-English summary

CareFusion 303, Inc. is recalling six units of the BD PYXIS MEDBANK TWR MN CR-6HH-2FH-2FM-P automated medication dispensing cabinet (REF: 169-93) due to a software issue in version 3.9.1.9.

The defect occurs when restock labels are printed for medications stored in the cabinet. Due to the software error, the printed label may display the incorrect bin location for the medication. This could result in pharmacy staff or users selecting and dispensing the wrong medication to patients.

The affected units have been distributed nationwide across the United States. Healthcare facilities that have received these units should immediately verify medication bin locations match printed labels before dispensing medications, and contact the manufacturer or the FDA if they have questions or concerns.

No illnesses or injuries have been reported at this time.

The recalled product

Product
BD PYXIS MEDBANK TWR MN CR-6HH-2FH-2FM-P, REF: 169-93 containing software version 3.9.1.9
Affected units
6

Distribution

Distributed nationwide across the United States.

The notice also names 41 states specifically:

Part of a larger recall action

This product is one of 19 recalled by CareFusion 303, Inc. under a single FDA (Devices) recall action. The agency files each product separately, so the size of the action is not visible from this page alone.

See all 19 products in this recall →