—#216381

Product

BD Pyxis MedStation ES, REF: 323, BD Pyxis MedStation ES 7 Drawer Auxiliary, REF: 324, BD Pyxis MedStation ES Tower, REF: 352, BD Pyxis Pro 7-Drawer Auxiliary, REF: 1149-00, BD Pyxis Pro 7- Drawer Auxiliary with Secure Tower, REF: 1152-00, BD Pyxis Pro MedStation Main, REF: 1155-00, BD Pyxis CII Safe ES, REF: 1116-00

FDA product code: BRY — Cabinet, Table And Tray, Anesthesia
Device class: Class 1
Medical specialty: Anesthesiology
Affected lot / code info: Firmware Version: 1.48. REF/UDI-DI: 323/10885403512667, 324/10885403512681, 352/10885403512674, 1149-00/10885403517822, 1152-00/10885403517839, 1155-00/10885403521300, 1116-00/10885403512605

Why it was recalled

Automated Dispensing Cabinets (ADC) received a Half Height CUBIE drawer firmware update, which caused a Cubie Insert event which prompts software to generate a duplicate address, which causes an error and the drawer to fail, which may lead to inability or delay in accessing stored items, delay in the replenishment of ADCs or patient specific medications stored outside of ADCs.

Root cause (FDA determination)

Device Design

Action the firm took

On 11/20/2025, correction notices were mailed and emailed to customers: 1) If a pocket fails with the error message of "Duplicate Address Detected," users with the proper permissions can leverage the "Recover Storage Space" functionality to eject the affected pocket and clear the error. Note: This does not resolve the Firmware v1.48 issue. This only clears the error message from the "Recover Storage Space" screen. Content stored within the affected CUBIE pocket will still need to be manually accessed once the CUBIE pocket is ejected. 2) Facilities should have comprehensive policies and procedures that outline alternative ways to access items, which may include removing from a different device or from pharmacy. 3. A redundant supply of all life sustaining medication should be kept in a nearby location to help mitigate the length of delay. 4. Firm recommends making a "code-box" or "crash cart" of medications that are readily available outside of an automated storage device in the event of an emergency. Facility policies and procedures should clearly identify when it is appropriate to access emergency medications. Refer to product user guide for additional information. 5. Keys can be used to manually access unavailable drawers. Keys must be readily available and retrievable to constitute risk mitigation. Hospital policies and procedures should be devised by the facility indicating location of keys along with how they are to be obtained and used in downtime scenarios. 6. Share and disseminate this notice within your facility network. 7. Complete and return the response form via email to BDRC21@bd.com Firm will install the firmware 1.49 upgrade either remotely or via a field service visit. Note: Firmware updates to main devices will update the Aux when connected to the main device. Firm contacts: Remediation Support: US-Pyxis-Field-Action-Remediation@bd.com Technical Support: bd.com/self-service, Phone:1-800-727-6102

Recalling firm

Firm: CareFusion 303, Inc.
Address: 10020 Pacific Mesa Blvd, San Diego, California 92121-4386

Distribution

Distribution pattern: Worldwide - US Nationwide distribution including in the states of CO, IN, OH, TX, KS, FL, GA, NC, CA, HI, IL, NY, MI, VA, AL, LA, NE, KY, OK, AR, TN, WY, NJ, WI, SD, AZ, NV, MO, MA, ID, WV, DE, PA, WA, MT, CT, IA, MD, PR, MN, NM, OR, VT, MS, ME, AK, UT, DC, GU, SC, NH, RI, ND, AS and the countries of CH, CA, KW, QA, NL, GB, UY, AU, NZ, BH, TH, SG, CN, FR, LB, BS, HK, TR, PL, AR, BR, CL, CO, MX, ES, BM, SA, IL.

Timeline

Recall initiated: 2025-11-20
Posted by FDA: 2025-12-19
Status: —

Source: openFDA Device Recall endpoint. Recall record ID #216381. The FDA issues recall classifications as health-hazard assessments, not legal findings; for legal claims consult a licensed attorney.