BD PYXIS MEDBANK (Name, REF): MEDPASS MODULE, 139088-01; MINI 1FH-1FM, 169-137; MINI 1HH-1FH-1...
FDA Device Recall #Z-1639-2025 — Class II — March 11, 2025
Recall Summary
| Recall Number | Z-1639-2025 |
| Classification | Class II — Moderate risk |
| Date Initiated | March 11, 2025 |
| Status | Ongoing |
| Voluntary | Voluntary: Firm initiated |
Recalling Firm
| Firm | CareFusion 303, Inc. |
| Location | San Diego, CA |
| Product Type | Devices |
| Quantity | 7,357 |
Product Description
BD PYXIS MEDBANK (Name, REF): MEDPASS MODULE, 139088-01; MINI 1FH-1FM, 169-137; MINI 1HH-1FH-1HM, 169-101; MINI 1HH-1HM-1FM, 169-102; MINI 2FH, 138902-01; MINI 2FH, 169-104; MINI 2FM, 169-105; MINI 2HH-1FH, 169-106; MINI 2HH-1FH, 138908-01; MINI 2HH-1FM, 169-107; MINI 2HH-1FM, 138906-01; MINI 3HH-1FG, 169-110; MINI 3HH-1FG, 139091-01; MINI 3HH-1HM, 169-111; MINI 4HH, 138910-01; MINI 4HH, 169-112; MINI 4HM, 169-113; MINI 4HM, 138915-01; TWR MN 10HH-1FH-1FM, 169-23; TWR MN 10HH-2FH, 169-24; TWR MN 10HH-2FH, 138955-01; TWR MN 10HH-2FM, 169-25; TWR MN 10HH-2FM, 138924-01; TWR MN 12HH-1FF, 169-26; TWR MN 12HH-1FF, 138960-01; TWR MN 12HH-1FH, 169-27; TWR MN 12HH-1FH, 138961-01; TWR MN 12HH-1FM, 169-28; TWR MN 12HH-1FM, 138926-01; TWR MN 14HH, 138927-01; TWR MN 14HH, 169-29; TWR MN 1HH-1HM-2FM-4FF, 169-30; TWR MN 2FH-2HM-4FM, 169-31; TWR MN 2HH-10HM-1FM, 169-32; TWR MN 2HH-1FH-5FM, 169-33; TWR MN 2HH-2FH-4FM, 169-34; TWR MN 2HH-4FH-2FM, 169-139; TWR MN 2HH-4HM-4FM, 139125-01; TWR MN 2HH-6FM, 169-38; TWR MN 2HH-6FM, 138919-01; TWR MN 2HH-6HM-3FM, 169-39; TWR MN 2HH-8HM-2FM, 169-40; TWR MN 2HM-6FM, 169-41; TWR MN 3FH-4FM, 169-42; TWR MN 3FH-4FM, 138933-01; TWR MN 3FH-8HH MEDPASS, 169-140; TWR MN 3HH-7HM-2FM, 169-43; TWR MN 4HH-10HM, 169-44; TWR MN 4HH-10HM, 138959-01; TWR MN 4HH-1FH-2HM-3FM, 169-45; TWR MN 4HH-1FH-4FM, 169-46; TWR MN 4HH-1FH-4HM-2FM, 169-47; TWR MN 4HH-2FH-2HM-2FM, 169-49; TWR MN 4HH-2FH-3FM, 169-50; TWR MN 4HH-2FH-3FM, 138931-01; TWR MN 4HH-3FH-2FM, 169-52; TWR MN 4HH-4FH-1FM, 169-53; TWR MN 4HH-4FH-1FM, 138940-01; TWR MN 4HH-4HM-3FM, 169-54; TWR MN 4HH-4HM-3FM, 138952-01; TWR MN 4HH-5FH, 169-55; TWR MN 4HH-5FM, 169-56; TWR MN 4HH-5FM, 138918-01; TWR MN 4HH-6HM-2FM, 169-57; TWR MN 4HM-5FM, 169-59; TWR MN 5HH-3HM-3FM, 169-60; TWR MN 5HH-9HM, 138914-01; TWR MN 5HH-9HM, 169-61; TWR MN 6FH-1FM, 169-62; TWR MN 6HH-1FH-2HM-2FM, 169-63; TWR MN 6HH-1FH-3FM, 169-64; TWR MN 6HH-2FH-2FM, 169-65; TWR MN 6HH-4FH, 169-67; TWR MN 6HH-4FH, 138957-01; TWR MN 6HH-4FM, 169-68; TWR MN 6HH-4FM, 138922-01; TWR MN 6HH-4HM-2FM, 169-69; TWR MN 6HH-8HM, 169-71; TWR MN 6HH-8HM, 138958-01; TWR MN 7FH, 169-72; TWR MN 7FH, 138920-01; TWR MN 7FM, 169-73; TWR MN 7FM, 138937-01; TWR MN 7HH-1HM-3FM, 139086-01; TWR MN 7HH-1HM-3FM, 169-74; TWR MN 8HH-1FH-2FM, 169-75; TWR MN 8HH-2FH-1FM, 169-77; TWR MN 8HH-2HM-2FM, 169-78; TWR MN 8HH-2HM-2FM, 138939-01; TWR MN 8HH-3FF, 169-79; TWR MN 8HH-3FH, 169-80; TWR MN 8HH-3FH, 138956-01; TWR MN 8HH-3FM, 169-81; TWR MN 8HH-3FM, 138923-01. BD PYXIS MEDFLEX MN (Name, REF): 1000 12HH, 139055-01; 1000 2HH-2FM, 139041-01; 1000 2HH-5FM, 139046-01; 1000 4HH-4FM, 139049-01; 1000 6HH-3FM, 139051-01; 1000 8HH-2FM, 139052-01; 2000 8HH-2FH, 139165-01; 2000 8HH-2FM, 139069-01. MEDBANK MAIN, 1137-00; MEDBANK MINI MAIN, 1147-00; MEDBANK TOWER MAIN, 1145-00; MEDFLEX, 1119-00; MEDFLEX 2.0, 1139-00
Reason for Recall
Users trying to restock a single bin location of an automated dispensing cabinet, during pocket exchange restocking workflow, may experience a software issue that results in 2 destock transactions and 2 stock transactions, which results in doubling the bin quantity, which may result in a delay in access to desired medications and/or supplies, which may lead to temporary body function impairment.
Distribution Pattern
US Nationwide distribution including in the states of MO, MI, FL, PA, SC, OR, AZ, CO, ND, GA, NE, TX, IL, OH, VT, IN, TN, KY, IA, MT, NY, CA, UT, OK, SD, WA, AK, ME, NV, NM, NC, WV, LA, MN, ID, AL, VA, WI, NH, KS, MA, CT, RI, NJ, MD, MS, WY, DC, DE, HI, AR, ON.
Lot / Code Information
REF/UDI-DI(GTIN)/Software Version: 139088-01/1.2.3.23; 169-137/10885403512544/2.4; 169-101/10885403512544/2.4; 169-102/10885403512544/2.4; 138902-01/2.4; 169-104/10885403512544/2.4; 169-105/10885403512544/2.4; 169-106/10885403512544/2.4; 138908-01/2.4; 169-107/10885403512544/2.4; 138906-01/2.4; 169-108/10885403512544/2.4; 169-110/10885403512544/2.4; 139091-01/2.4; 169-111/10885403512544/2.4; 138910-01/2.4; 169-112/10885403512544/2.4; 169-113/10885403512544/2.4; 138915-01/2.4; 169-23/10885403512568/2.4; 169-24/10885403512568/2.4; 138955-01/2.4; 169-25/10885403512568/2.4; 138924-01/2.4; 169-26/10885403512568/2.4; 138960-01/2.4; 169-27/10885403512568/2.4; 138961-01/2.4; 169-28/10885403512568/2.4; 138926-01/2.4; 138927-01/2.4; 169-29/10885403512568/2.4; 169-30/10885403512568/2.4; 169-31/10885403512568/2.4; 169-32/10885403512568/2.4; 169-33/10885403512568/2.4; 169-34/10885403512568/2.4; 169-139/10885403512568/2.4; 139125-01/2.4; 169-38/10885403512568/2.4; 138919-01/2.4; 169-39/10885403512568/2.4; 169-40/10885403512568/2.4; 169-41/10885403512568/2.4; 169-42/10885403512568/2.4; 138933-01/2.4; 169-140/10885403512568/1.2.3.23; 169-43/10885403512568/2.4; 169-44/10885403512568/2.4; 138959-01/2.4; 169-45/10885403512568/2.4; 169-46/10885403512568/2.4; 169-47/10885403512568/2.4; 169-49/10885403512568/2.4; 169-50/10885403512568/2.4; 138931-01/2.4; 169-52/10885403512568/2.4; 169-53/10885403512568/2.4; 138940-01/2.4; 169-54/10885403512568/2.4; 138952-01/2.4; 169-55/10885403512568/2.4; 169-56/10885403512568/2.4; 138918-01/2.4; 169-57/10885403512568/2.4; 169-59/10885403512568/2.4; 169-60/10885403512568/2.4; 138914-01/2.4; 169-61/10885403512568/2.4; 169-62/10885403512568/2.4; 169-63/10885403512568/2.4; 169-64/10885403512568/2.4; 169-65/10885403512568/2.4; 169-67/10885403512568/2.4; 138957-01/2.4; 169-68/10885403512568/2.4; 138922-01/2.4; 169-69/10885403512568/2.4; 169-71/10885403512568/2.4; 138958-01/2.4; 169-72/10885403512568/2.4; 138920-01/2.4; 169-73/10885403512568/2.4; 138937-01/2.4; 139086-01/2.4; 169-74/10885403512568/2.4; 169-75/10885403512568/2.4; 169-77/10885403512568/2.4; 169-78/10885403512568/2.4; 138939-01/2.4; 169-79/10885403512568/2.4; 169-80/10885403512568/2.4; 138956-01/2.4; 169-81/10885403512568/2.4; 138923-01/2.4; 139055-01/2.4; 139041-01/2.4; 139046-01/2.4; 139049-01/2.4; 139051-01/2.4; 139052-01/2.4; 139165-01/2.4; 139069-01/2.4; 1137-00/2.4; 1147-00/10885403517181/2.4; 1145-00/10885403517167/2.4; 1119-00/10885403512704/2.4; 1139-00/10885403512704/2.4
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| Z-1645-2026 | Class II | BD Alaris" System with Guardrails" Suite MX wit... | Feb 11, 2026 |
| Z-1028-2026 | Class II | BD Pyxis ES Enterprise Server Catalog Numbers 1... | Dec 3, 2025 |
| Z-0962-2026 | Class II | BD Pyxis MedStation ES, REF: 323, BD Pyxis M... | Nov 20, 2025 |
| Z-1217-2026 | Class II | BD Alaris" Pump Module model 8100 UDI-DI code:... | Nov 6, 2025 |
| Z-0430-2026 | Class I | BD Alaris infusion Pump Module 8100, REF: 8100;... | Oct 17, 2025 |
Frequently Asked Questions
A software recall means the device's embedded software or firmware has a defect that could affect its performance or safety. Many software recalls are corrected through firmware updates that can be applied without physically replacing the device. For implantable devices, the update may be delivered wirelessly during a routine clinic visit. For external devices, the manufacturer may provide updated software files or replacement units. Contact your healthcare provider to determine whether your specific device and software version are affected and what action is recommended.
Class I recalls indicate a reasonable probability of serious adverse health consequences or death from the defect. Class II recalls involve products that may cause temporary or medically reversible adverse health consequences, or where serious consequences are remote. Class III recalls cover products not likely to cause any adverse health consequences, typically involving technical regulatory violations. The classification guides urgency — Class I recalls require immediate action, while Class III may simply involve returning a product or acknowledging a labeling change. Always read the specific recall notice for recommended patient actions.
Report problems with medical devices to the FDA through MedWatch at 1-800-FDA-1088 or online at FDA.gov/safety/medwatch. Healthcare facilities are required by law to report device-related serious injuries and deaths. Patients and consumers can also report voluntarily. Include the device name, manufacturer, model number, and a description of the problem and any patient outcome. Reports from patients and clinicians help the FDA identify emerging safety signals and may trigger investigations that lead to recalls of dangerous devices.
What Should You Do?
Stop using this device if you are affected by this recall. Contact your healthcare provider and the manufacturer immediately for guidance. Report adverse events to FDA MedWatch.