After dispensing a timed dose medication for a patient, the automated dispensing cabinet software may continue to show the already dispensed medication dose is still available for dispense, which could lead to duplicate medication administration.
Take action
Contact the company
📍Recalling firmCareFusion 303, Inc.10020 Pacific Mesa Blvd · San Diego, CA 92121-4386
“BD Pyxis MedBank MedPass Software Recall: Duplicate Medication Risk.” GovInfoNow, updated August 17, 2026. https://govinfonow.com/recall/57462-bd-pyxis-medbank-medpass-software-recall-duplicate-medication-risk. Based on FDA recall #Z-2646-2023 (https://api.fda.gov/device/enforcement.json?search=recall_number:%22Z-2646-2023%22&limit=1).
The FDA announced on Aug. 18, 2023, that CareFusion 303, Inc. is recalling BD Pyxis MedBank MedPass Software due to a hazard that could lead to duplicate medication administration. The agency stated the software may incorrectly show dispensed doses as still available.
How to tell if you have it
Brand: BD
Product: BD Pyxis MedBank MedPass Software
REF: 139088-01
UDI-DI: 10885403513817
Software versions prior to but not including v1.2.3.23
The hazard
According to the FDA, after dispensing a timed dose medication for a patient, the automated dispensing cabinet software may continue to show the already dispensed medication dose is still available for dispense. This error could lead to duplicate medication administration.
Context
GovInfoNow's records show CareFusion 303, Inc. has 64 other recalls on record since 2017-06-12. Other recent recalls of similar products include Fresenius Kabi Ivenix Infusion System Software Recall (2025-11-14), B Braun Medical Blood Set Recall (2025-10-29) and B Braun IV Sets Risk Backflow of Medication - Recall (2025-10-29).
How to tell if you have this one
Check if your software version is below v1.2.3.2:139088-01. The software was sold with BD Pyxis MedBank MedPass systems starting from 2018.
Brand
BD
Category
Medical device
Based on the official FDA remedy
What to do — step by step
Update Software
Install version v1.2.3.23 or later to fix the duplicate dispensing issue.
Where it went and when
Where it was distributed
Distributed in 3 states.
Listed by the agency
Not listed
FDA distribution: “US: FL, MI, KS” States read from FDA’s own wording; “not listed” means the notice does not name it.
States: Florida, Kansas, Michigan.
Recall timeline
FDA published this recall 47 days after the firm started it.
1Firm started the recall
2FDA classified it Class II
3Published in FDA’s Enforcement Report
Dates from the agency record only; steps without a date are left out.
The facts (hazard, remedy, dates, manufacturer) are pulled from the official FDA recall record. The plain-language summary and step-by-step checklist are written by GovInfoNow to make the official notice easier to act on — they don’t replace it.
Official source: FDA Recall #Z-2646-2023 (August 18, 2023) — FDA publishes no per-recall page; this is the official machine-readable enforcement record. Search FDA recalls for Z-2646-2023 to see it in context.
Plain-language summary written by qwen3:4b on August 17, 2026, from the official record above. Not reviewed by a person — if it conflicts with the FDA notice, the notice is correct. Report an error on this page.
GovInfoNow is an independent service and is not a government agency. We republish official FDA recall data; we don’t issue, amend or administer recalls.