BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    BD PYXIS¿ ES SERVER

    MDR report key: 25162108 · Received May 13, 2026

    Report

    Report Number
    2016493-2026-28699
    Event Type
    Malfunction
    Date Received
    May 13, 2026
    Date of Event
    April 16, 2026
    Report Date
    April 17, 2026
    Manufacturer
    CAREFUSION 303, INC.
    Product Code
    BRY
    PMA / PMN Number
    EXEMPT
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    VA, US
    Reporter Occupation
    PHARMACIST
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    D4 & H4: SERIAL NUMBER, CATALOG, MODEL, UNIQUE DEVICE IDENTIFIER AND MANUFACTURER DATE NOT AVAILABLE. UPON INVESTIGATION OF THE ACTUAL DEVICE USED IN THIS INCIDENT, IT WAS DETERMINED THAT THE ORDERED MEDS NOT LOADED (OMNL) REPORT NOT UPDATING CORRECTLY FOR ALL PYXIS DEVICES, SPECIFICALLY SHOWING PATIENTS WHO HAD ALREADY BEEN DISCHARGED. A TECHNICAL SUPPORT SPECIALIST (TSS) CONFIRMED THAT PROBLEM AFFECTED ALL INPATIENT UNITS AND ORIGINATED AFTER THE BETHESDA SERVER CRASH IN MARCH, WHEN DISCHARGE MESSAGES FROM GENESIS DID NOT FULLY CROSS OVER TO THE PYXIS SERVER, LEAVING MULTIPLE PATIENTS INCORRECTLY MARKED AS ACTIVE. ALTHOUGH THE AFFECTED PATIENTS HAD VALID DISCHARGE ENCOUNTERS IN GENESIS, DISCHARGE STATUS WAS MISSING ON THE PYXIS SERVER, CAUSING MEDICATION ORDERS TO REMAIN ON THE OMNL REPORT. INITIAL DATABASE ADJUSTMENTS TO THE REPORT SERVER DID NOT RESOLVE THE ISSUE. FURTHER REVIEW CONFIRMED THAT THE IMPACTED PATIENTS WERE STILL ACTIVE ON THE PYXIS SERVER, LIKELY DUE TO MISSED DISCHARGE MESSAGES DURING THE DISASTER RECOVERY PERIOD. AFTER RECEIVING AN ENCRYPTED LIST OF AFFECTED PATIENT ENCOUNTERS, THE PATIENTS WERE MANUALLY DISCHARGED ON THE PYXIS SERVER. FOLLOWING THESE UPDATES, THE CUSTOMER VERIFIED THAT THE OMNL REPORT WAS ACCURATE AND NO LONGER DISPLAYED DISCHARGED PATIENTS, CONFIRMING THE ISSUE WAS RESOLVED. THE SYSTEM FUNCTIONED AS INTENDED AFTER THE TECHNICAL SUPPORT SPECIALIST TROUBLESHOT THE DEVICE.

    Description of Event or Problem · 0

    IT WAS REPORTED THAT WHEN USING THE BD PYXIS¿ ES SERVER, MEDICATIONS WAS NOT LOADED REPORT WITH THE LIST OF PATIENTS ADMITTED OR DISCHARGED. THE CUSTOMER REPORTED THAT THERE WAS A DELAY IN PATIENT CARE. THERE WERE NO ADVERSE EVENTS OR INJURIES REPORTED BASED ON THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    76006 BD PYXIS¿ ES SERVER AUTOMATED DISPENSING CABINET BRY CAREFUSION 303, INC.

    Patients

    Seq Age Sex Outcome Treatment
    1 NA Unknown SN - (B)(6) LN - FB-ORMDPRP