| | Class 2 Device Recall BD Pyxis |  |
| Date Initiated by Firm | February 14, 2023 |
| Date Posted | March 17, 2023 |
| Recall Status1 |
Open3, Classified |
| Recall Number | Z-1207-2023 |
| Recall Event ID |
91341 |
| Product Classification |
Cabinet, table and tray, anesthesia - Product Code BRY
|
| Product | BD Pyxis Anesthesia ES System (PAS ES), REF: 327; BP Pyxis MedStation ES (Med ES Main), REF: 323; BD Pyxis MedStation ES Tower (Med ES Tower), REF: 352; all with BD Pyxis ES version 1.6.1 drawer firmware (version 1.10.2.5). Pyxis MedStation Enterprise Server (ES) System is an automated medication dispensing system supporting decentralized medication management in a pharmaceutical environment. |
| Code Information |
REF/UDI-DI: 327/10885403477836, 323/10885403512667, 352/10885403512674 |
Recalling Firm/ Manufacturer |
CareFusion 303, Inc. 10020 Pacific Mesa Blvd San Diego CA 92121-4386
|
| For Additional Information Contact | 888-876-7128 |
Manufacturer Reason for Recall | Automated dispensing cabinet drawer firmware may have inadvertently been downgraded to an earlier version of drawer firmware during new device installations or device replacement upgrades, which may lead to an increased frequency of drawer failures, which could increase the likelihood of patients experiencing delays in receiving medications. |
FDA Determined Cause 2 | Software change control |
| Action | On 01/14/23, correction notices were mailed to directors of pharmacy informing them to take the following actions:
1) Ensure this letter and contents are forwarded and/or discussed with all appropriate personnel to ensure proper awareness of the issue.
2) If you are experiencing any issues, such as drawer failures, call BD technical support and refer to user guides for additional information and troubleshooting procedures.
a. BD Pyxis MedStation ES user guide, refer to sections "Recover storage space" (Chapter 9, pg. 76) and "Emergency medication removal" (Appendix 11, pg. 119). See references 1 and 2 below for additional details.
b. BD Pyxis PAS ES user guide, refer to sections "Emergency access procedures" (Appendix A, pg. 77) and "Storage spaces are not responsive" (Appendix B, pg. 81). See references 3 and 4 below for additional details.
3) Complete and return the Customer Response Form.
The firm will take the following actions:
1) All customers who may have affected devices will be notified.
2) Upon receipt of completed response forms, the firm will coordinate the firmware upgrade with customers.
Technical Support: 1-800-727-6102, Phone hours: 24 hours, 7 days a week
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| Quantity in Commerce | 7914 |
| Distribution | Worldwide - US Nationwide distribution including in the states of NY, PA, OH, TX, FL, KY, IL, DE, AK, WI, KS, LA, WA, AZ, CO, MI, IN, TN, SD, AR, MO, CA, NV, MA, SC, VA, WV, CT, ME, NE, RI, GA, NC, IA, MN, AL, OK, MS, NM, NH, VT, WY, OR, ID, NJ, UT, DC, HI, MD, MT, ND and the country of Canada. |
| Total Product Life Cycle | TPLC Device Report |
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1 A record in this database is created when a firm initiates a correction or removal action. The record is updated if the FDA identifies a violation and classifies the action as a recall, and it is updated for a final time when the recall is terminated. Learn more about medical device recalls. 2 Per FDA policy, recall cause determinations are subject to modification up to the point of termination of the recall. 3 The manufacturer has initiated the recall and not all products have been corrected or removed. This record will be updated as the status changes.
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