[Mix-up of patient specimens: error prevention through a systems approach]

A correct diagnosis may reach the wrong patient because of a mix-up of either diagnostic specimens or identification data. It is astonishing how little attention is paid to this problem in medicine while the scale, the reach and the complexity of diagnosis are growing fast. More research is urgently needed to detect and investigate these types of errors. There is no quick remedy for this problem: a systems approach with comprehensive assessment of potential risks and subsequent management is the only sensible way out. Regrettably it is impossible to completely eliminate swapping errors, at best they can be reduced to an absolute minimum.