A single lab error led to an unnecessary surgery—and revealed how easily systems can fail patients when learning stops.
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This week’s “Mistake of the Week” comes from Basel University Hospital, where a woman underwent an unnecessary cervical surgery after her lab sample was mixed up with another patient’s. The error wasn’t discovered until after the operation, and she wasn’t informed for two months.
It’s a painful reminder that specimen-handling errors still occur—and that being “careful” isn’t enough. As I wrote about a similar case in 2009, these are systemic breakdowns, not individual failings. Humans are fallible; processes must be designed to prevent mix-ups through true error proofing.
The hospital has announced steps to prevent recurrence, but steps aren’t systems. Sustainable safety comes from robust processes, psychological safety that encourages speaking up, and a culture that learns—rather than hides—mistakes.
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Transcript:
Introduction
Hi, welcome to My Favorite Mistake. I'm Mark Graban, and this is your mistake of the week. This week's story comes from Switzerland, from Basel University Hospital, and it's one of those moments that makes you pause and wonder: how does something like this still happen?
The Surgery Error
In 2025, a woman underwent surgery she didn't need because her laboratory sample had been mixed up with somebody else's. Doctors believed she had cervical cancer. She did not, but the surgery went ahead anyway, shortening her cervix and creating potential risks for future pregnancies.
The mistake came from a sample mix-up in the hospital's lab; two patients' specimens were swapped during processing. This shouldn't happen. The mistake wasn't caught until after the operation when the tissue that had been removed showed no cancer cells at all.
The Aftermath and Compensation
The woman, named Sarah, only learned about the mistake two months later. Her reaction was a mix of disbelief, anger, and loss. She told Swiss Media she now fears the surgery could affect her ability to have children.
The hospital's liability insurer initially offered her compensation of 1,000 francs, roughly the cost of a long weekend in Zurich. After public pressure and coverage on Swiss television, that offer increased to 4,000 francs and coverage for any future complications. Still, that's a small price for an error that can't be undone.
Systemic Failures vs. Human Error
Now, Basel University Hospital says it's taken steps to prevent similar mix-ups, but steps aren't the same as systems. This kind of mix-up unfortunately isn't new. Back in 2009, I wrote about a nearly identical case in New York—a woman who had a mastectomy after her biopsy was labeled with somebody else's name. Different country, different year, same story.
As I said then, being careful isn't enough. Humans are fallible. That's not a flaw; it's a reality. The real mistake is designing a process that assumes perfection.
In terms of the lean management methodology, this is a failure of error-proofing or a lack of error-proofing. We should design laboratory workflows so that a specimen can't be mislabeled or swapped with another patient's, full stop. Yet too often, staff are pushed to multitask, batch up their work, or hurry through their process, creating perfect conditions for human error.
Conclusion
When a mistake like this happens, sadly, somebody usually gets blamed or fired, but that doesn't fix the process. It just hides the problem until it happens again. The real tragedy here isn't that one person made a mistake. The tragedy is that mistakes like this continue to happen in hospital laboratories because it's the system that makes it possible. Healthcare can't rely on vigilance or heroics alone. We need processes that make it harder for mistakes to reach patients—or better yet, impossible—and leadership cultures that turn harm into learning, not shame.
For My Favorite Mistake on Mark Graban, remember: mistakes don't define us; how we respond to them does.