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Recall data is sourced from official U.S. government agencies (CPSC, FDA, NHTSA, USDA) and processed using AI to improve readability. This site is not affiliated with or endorsed by any government agency. Always refer to the original agency notice for authoritative information.

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Medium RiskFDA Device
Medical Devices/Monitoring Devices

CareFusion 303, Inc.: BD Pyxis CII Safe ES Recalled for Software Defect Enabling Drug Diversion

Agency Publication Date: October 10, 2023
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Summary

Approximately 61 units of the BD Pyxis CII Safe ES and Enterprise Server products are being recalled because a software defect can silently overwrite critical security settings. When using the 'global edit' feature to update multiple settings at once, the system automatically changes several important security controls—such as requiring a witness for medication destruction—to 'NO' without warning the user. This issue affects software versions 1.7.3 and 1.7.4, which were distributed across several states including California, Michigan, and New York.

Risk

The software defect disables security protocols designed to track controlled substances, which could result in the unauthorized diversion of high-risk medications from automated dispensing cabinets without detection. This failure of the inventory control system poses a medium risk to hospital security and patient safety by allowing controlled substances to be removed or destroyed without the required oversight.

What You Should Do

  1. Identify if your facility is using the BD Pyxis CII Safe ES (REF: 1116-00), Enterprise Server, or related Desktop PC scanners with Software Versions 1.7.3 or 1.7.4.
  2. Check the 'Global Edit' logs to see if settings were recently updated for the following properties: Require Lot Number on Recall, Access Destruction Bin (Witness), Add to Destruction Bin (Count/Empty), and CII Safe Stock Out Notice.
  3. Immediately verify that these security properties are set to the correct facility-required values and manually change any that were incorrectly set to 'NO' by the software.
  4. Contact the manufacturer, CareFusion 303, Inc., at their San Diego office or via their support portal to discuss software patches or updates to resolve this defect.
  5. Notify your healthcare provider or facility risk manager if you suspect any diversion of controlled substances has occurred due to this software issue.
  6. For additional questions or to report further issues, contact the FDA at 1-888-463-6332 (1-888-INFO-FDA) or visit www.fda.gov/medical-devices/medical-device-recalls.

Your Remedy Options

📋Other Action

Manufacturer initiated contact via letter to address software settings overwriting.

How to: Contact your healthcare provider or the manufacturer for further instructions and potential refund

Affected Products

Product: BD Pyxis CII Safe ES
Model / REF:
1116-00
Lot Numbers:
UDI-DI: 10885403512605
Date Ranges: Software Versions: 1.7.3 and 1.7.4
Product: BD Pyxis: CII Safe ES Desktop PC, Wired SCNR
Model / REF:
107-254-01
Date Ranges: Software Versions: 1.7.3 and 1.7.4
Product: BD Pyxis: CII Safe ES Desktop PC, W-LESS SCNR, BIO
Model / REF:
107-255-01
Date Ranges: Software Versions: 1.7.3 and 1.7.4
Product: BD Pyxis: Enterprise Server
Model / REF:
1115-00
134157-01
137670-02
134148-01
135292-01
136449-01
133760-01
Date Ranges: Software Versions: 1.7.3 and 1.7.4

Additional Information

Agency: Food and Drug Administration (FDA)
Event ID: 93016
Status: Active
Manufacturer: CareFusion 303, Inc.
Sold By: CareFusion 303, Inc.; BD (Becton, Dickinson and Company)
Manufactured In: United States
Units Affected: 61
Distributed To: Louisiana, North Carolina, New York, Michigan, Massachusetts, Nevada, Kansas, Iowa, California

Were You Affected by This Recall?

If you or a family member were harmed by this recalled product, you may have legal rights. Consider consulting a consumer protection attorney to understand your options for compensation.

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This is general information, not legal advice. Go Backs is not a law firm and does not provide legal services.

AI-Enhanced Content: The summary, action steps, and risk assessment on this page were generated by AI from official government recall data to improve readability. This is not legal or medical advice. Always refer to the official agency sources below for authoritative information.

Sources: FDA iRES · Raw API Response

openFDA Disclaimer: This recall information is sourced from the openFDA API. Do not rely on openFDA to make decisions regarding medical care. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Refer to the openFDA terms of service for more information.