BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    BD PYXIS MEDBANK TWR MN 12HH-1FH

    MDR report key: 23520052 · Received November 11, 2025

    Report

    Report Number
    2016493-2025-132655
    Event Type
    Malfunction
    Date Received
    November 11, 2025
    Date of Event
    November 18, 2023
    Report Date
    November 4, 2025
    Manufacturer
    CAREFUSION 303, INC.
    Product Code
    BRY
    UDI-DI
    10885403512568
    PMA / PMN Number
    EXEMPT
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IN, US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    THIS MDR IS BEING SUBMITTED AS PART OF A RETROSPECTIVE REVIEW OF RECORDS DATING JANUARY 2022-DECEMBER 5, 2024, UNDER CAPA 10308384. THE LATE SUBMISSION OF THIS REPORT IS JUSTIFIED BY THE THOROUGH AND DETAILED NATURE OF THE RETROSPECTIVE REVIEW PROCESS. THIS PROCESS WAS ESSENTIAL TO ACCURATELY CAPTURE ALL RELEVANT DATA AND ENSURE THE INTEGRITY OF OUR REPORTING. WE HAVE INCLUDED THE CAPA REFERENCE FOR THE RETROSPECTIVE REVIEW IN THE ADDITIONAL MANUFACTURER NARRATIVE SECTION OF THE FDA FORM 3500A, AS RECOMMENDED. A REVIEW OF THE COMPLAINT HISTORY FOR SN (B)(6) WAS PERFORMED IN SALESFORCE WHICH DID NOT LOCATE SIMILAR COMPLAINTS WITH THE SAME FAILURE MODE FOR THIS SERIAL NUMBER. A REVIEW OF THE DEVICE HISTORY RECORD FOR SN (B)(6) WAS PERFORMED FROM THE DATE OF MANUFACTURE, 16-MAY-2022 AND CONFIRMED THAT THIS DEVICE WAS NOT PREVIOUSLY RETURNED FOR SERVICING AND THERE WERE NO PRODUCTION FAILURES WHICH CORRELATES TO THE CUSTOMER REPORTED ISSUE. UPON INVESTIGATION OF THE ACTUAL DEVICE USED IN THIS INCIDENT, IT WAS DETERMINED THAT THE INVENTORY COUNT WAS INCORRECT WITH ZERO QOH FOR INSULIN. A TECHNICAL SUPPORT SPECIALIST ADVISED THE NURSES TO CONTACT THE PHARMACY AND INFORMED THEM THAT ACCESS TO THE FRIDGE ITEMS WAS STILL POSSIBLE USING THE KEY, BUT FIXING THE ISSUE WOULD REQUIRE AN ADMIN USER WITH CYCLE COUNT ACCESS. THE SYSTEM FUNCTIONED AS INTENDED AFTER THE TECHNICAL SUPPORT SPECIALIST TROUBLESHOT THE DEVICE.

    Description of Event or Problem · 0

    IT WAS REPORTED BY THE CUSTOMER THAT A BD PYXIS MEDBANK SYSTEM HAD AN INCORRECT INVENTORY COUNT WITH ZERO QOH FOR INSULIN. THERE WERE NO ADVERSE EVENTS OR INJURIES REPORTED BASED ON THIS INCIDENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1853716 BD PYXIS MEDBANK TWR MN 12HH-1FH AUTOMATED DISPENSING CABINET BRY CAREFUSION 303, INC. 169-27 10885403512568

    Patients

    Seq Age Sex Outcome Treatment
    1 NA Unknown