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Specimen Mislabeling Can Have Devastating Consequences - How Modern LIS Software Helps Reduce the Risk
August 14, 2026
In laboratory medicine, accuracy starts long before a pathologist reviews a slide or an analyzer produces a result. It begins with correctly identifying the patient and specimen, and maintaining that connection throughout the entire diagnostic process.
A recent case reported by Today's Clinical Lab provides a sobering reminder of what can happen when that connection potentially breaks down.
A Georgia woman has filed a negligence lawsuit against Kaiser Permanente alleging that a mislabeled pathology specimen resulted in a false cancer diagnosis, an unnecessary hysterectomy, and months of physical and emotional trauma.
According to the lawsuit, Cassandra Barksdale underwent a biopsy in March 2025 after seeking treatment for heavy bleeding and uterine fibroids. She was subsequently diagnosed with an aggressive form of endometrial cancer and underwent a full hysterectomy in May. Months later, DNA analysis reportedly determined that the cancerous tissue belonged to another patient. Where the alleged specimen mix-up occurred remains unclear.
The allegations underscore a fundamental principle for every clinical laboratory and pathology practice: specimen identification and tracking must remain accurate from collection through final diagnosis.
Full Article from Today’s Clinical Lab: Alleged Pathology Sample Mislabeling Leads to Unnecessary Hysterectomy, Lawsuit Against Kaiser Permanente
The Risks Associated With Specimen Mislabeling
A specimen identification error can occur at multiple points in the clinical laboratory workflow: collection, labeling, accessioning, grossing, processing, embedding, microtomy, slide preparation, testing, or reporting.
When laboratories rely on manual processes, handwritten documentation, disconnected systems, and repetitive data entry, each additional handoff increases the potential for human error.
The consequences can extend far beyond operational inefficiency.
A mislabeled or misidentified specimen may potentially contribute to an incorrect diagnosis, delayed treatment, unnecessary treatment, recollection procedures, amended reports, regulatory concerns, and significant legal and reputational exposure.
The College of American Pathologists (CAP) describes accurate labeling of paraffin blocks and microscopic slides as essential to patient safety and to reducing the potential for misdiagnosis resulting from improper specimen identification. CAP guidance recommends two patient identifiers on blocks and slides, along with unique accession identification.
That's why sample tracking should be viewed as a patient-safety requirement, not simply an operational convenience.
Discover More: CAP Guidelines for Labeling of Blocks and Slides in Surgical Pathology
How Modern Laboratory Information System Software Strengthens Specimen Tracking
Modern laboratory information system (LIS) software can provide laboratories with the infrastructure needed to establish positive specimen identification and maintain a digital chain of custody throughout the laboratory workflow.
Rather than relying on manual logs, handwritten labels, or staff memory, an advanced medical LIS assigns each case and specimen a unique identifier, enabling electronic tracking throughout every stage of the case lifecycle.
The goal is straightforward: maintain an accurate connection between the patient, order, specimen, container, block, slide, test, result, and final report.
CAP guidance for surgical pathology specimen handling states that unique specimen barcodes or RFID labels should remain consistent across specimen containers, requisition labels, cassettes, and slides.
With the best LIS software and specimen tracking technology, laboratories can build those safeguards directly into their everyday diagnostic processes.
Industry Insights: The Modern Laboratory Blueprint - Aligning People, Processes, and Technology for Long-Term Success
Barcode Specimen Tracking Creates a Digital Chain of Custody
Barcode technology is one of the most important components of modern laboratory sample tracking.
When specimens arrive at the laboratory, modern LIS systems can generate unique barcode identifiers that follow them through accessioning and subsequent processing. Lab personnel scan the barcode as the specimen moves from one workstation or workflow stage to another.
For anatomic pathology LIS laboratories, that tracking can extend from the original specimen container to cassettes, paraffin blocks, slides, and ultimately the pathology report.
CAP has noted that barcode technology has been shown to reduce specimen labeling errors and has supported its use in histology laboratories where available, while also emphasizing the importance of human-readable identifiers as an additional safeguard.
This combination of barcode sample tracking, positive patient identification, and LIS-driven lab workflow controls creates a stronger digital chain of custody.
Discover More: Beyond Risk - How LigoLab Fortifies Modern Clinical Laboratory Management
Automated Checks Help Catch Problems Before They Move Downstream
A modern laboratory information system should do more than record where a specimen is located. It can actively govern how work progresses.
Configurable rules, validation requirements, barcode scanning, exception alerts, and workflow checkpoints can help prevent a specimen from advancing when required information is missing or inconsistent.
For example, a modern LIS system may support workflows that require staff to verify identifiers, confirm specimen type, validate collection information, or scan a matching barcode before completing the next step.
Instead of discovering discrepancies after testing or reporting, laboratories can identify exceptions closer to where they occur.
This is an important distinction between legacy laboratory software systems and modern laboratory information system software designed to function as workflow orchestration platforms.
The latter doesn't simply document what happened. It uses rules and automation to help laboratory personnel determine what needs to happen next.
Industry Insights: From System of Record to System of Action - The Next Evolution of Laboratory Information Systems
Specimen Tracking Should Extend Across the Entire Pathology Workflow
Effective pathology specimen tracking software shouldn’t stop at accessioning.
Anatomic pathology cases can produce multiple derivative materials as they progress through the laboratory, including containers, cassettes, blocks, slides, special stains, and digital images.
Each derivative must remain traceable to the correct patient and original specimen.
CAP guidance states that secondary specimen containers should maintain adequate identification throughout testing. For histology, tissue blocks should carry unique identifiers traceable to the primary specimen, while slides should remain traceable to the blocks from which they were produced.
A comprehensive anatomic pathology LIS solution can support this level of traceability by maintaining parent-child relationships throughout the case.
That gives laboratory teams greater visibility into where specimens are, where they've been, what actions have been performed, and what steps remain.
Discover More: The Benefits of a Modern Pathology Lab Management System
LIS Lab Automation Also Creates an Audit Trail
Another key benefit of digital sample tracking software integrated into a modern medical LIS is greater accountability.
Barcode scans and electronic workflow events can create timestamps and audit trails documenting specimen movement and user activity. Rather than reconstructing events from paper logs or staff recollection, authorized laboratory personnel can review an electronic history.
This is valuable for quality assurance, process improvement, compliance, and the investigation of potential discrepancies.
CAP's quality programs specifically address misidentification of surgical pathology cases, specimens, blocks, and slides, noting that mislabeling can have potentially catastrophic consequences for patient care. CAP also references the requirement for a lab information system that positively identifies patient specimens, specimen types, and aliquots throughout the laboratory process.
Discover More: LigoLab’s Essential Tier - LIS Software Designed to Meet a Lab’s Basic Needs
Laboratory Information System Technology Is Only Part of the Solution
No laboratory information system, barcode scanner, or automation platform can guarantee that a specimen identification error will never occur.
Technology must operate alongside well-designed standard operating procedures, staff training, quality management, positive patient identification, standardized labeling practices, and ongoing monitoring.
CAP guidance reinforces this layered approach. Its specimen-handling recommendations combine identification standards with barcode or RFID technology, written procedures, and consistent labeling practices.
The objective should therefore be to create multiple safeguards that make errors harder to introduce and easier to detect before they affect patient care.
Modern LIS systems provide an important technological foundation for doing exactly that.
Discover More: See How LigoLab’s Laboratory Informatics Platform Rates in the CAP Today LIS System Product Guide
From Specimen Collection to Final Report: One Source of Truth
Disconnected laboratory software systems can create gaps in visibility. When accessioning, specimen tracking, testing, pathology workflows, and reporting operate independently, maintaining continuity becomes more difficult.
A unified laboratory information system platform creates a single source of truth so patient, order, specimen, testing, and reporting information remains connected.
For laboratories evaluating new LIS software, advanced specimen management capabilities should therefore include the following important capabilities:
- Barcode-based specimen identification and tracking
- Positive patient identification
- End-to-end sample traceability
- Automated accessioning workflows
- Configurable workflow rules and checkpoints
- Chain-of-custody tracking
- Parent-child specimen relationships
- Block and slide tracking for anatomic pathology
- Instrument and EHR interoperability
- Real-time specimen status visibility
- Exception alerts and work queues
- Comprehensive audit trails
- Automated laboratory workflow management
- Customizable quality-control rules
Together, these capabilities help laboratories replace vulnerable manual processes with standardized, traceable, and automated workflows.
White Paper: Comparing LigoLab Informatics Platform with Legacy Laboratory Information System Software
Specimen Tracking Is Ultimately About Patient Safety
The lawsuit highlighted by Today's Clinical Lab reinforces the critical importance of accurate specimen identification and tracking.
For laboratory leaders, the lesson extends far beyond a single incident or organization. Every specimen represents a patient whose diagnosis and treatment decisions may depend on the accuracy of the laboratory result.
By combining modern medical LIS technology with well-defined processes, properly trained personnel, and rigorous quality controls, laboratories can strengthen patient safety and create a more accurate, reliable, and traceable diagnostic process from specimen collection through final reporting.
Strengthen Specimen Tracking With a Modern LIS
Is your laboratory still relying on manual processes, disconnected systems, or legacy technology to manage specimen identification and tracking?
Contact a LigoLab product specialist to learn how modern LIS software can help your laboratory strengthen specimen traceability, improve workflow control, and reduce opportunities for preventable errors.
Act Now: Speak with a LigoLab Product Specialist!
Frequently Asked Questions About Sample Tracking and Advanced Laboratory Information System Software
What is sample tracking in a laboratory?
Laboratory sample tracking is the process of maintaining identification, location, status, and traceability of a patient specimen as it moves through the testing workflow. Modern medical LIS software can use unique identifiers, barcode scanning, timestamps, workflow events, and audit trails to maintain this digital chain of custody.
How does laboratory information system software help prevent specimen mislabeling?
A modern laboratory information system (LIS) can support positive specimen identification through barcode labeling, automated validation, workflow rules, scanning requirements, exception alerts, and audit trails. These safeguards can reduce dependence on manual processes and help identify discrepancies before specimens progress further through the workflow.
What is barcode specimen tracking?
Barcode specimen tracking assigns a machine-readable unique identifier to a specimen and its associated materials. Laboratory personnel scan these identifiers at defined workflow stages, enabling the LIS system to confirm specimen identity and electronically document movement through the laboratory.
Can LIS software eliminate specimen identification errors?
No technology can guarantee the complete elimination of specimen identification errors. A modern LIS medical solution should be part of a broader patient-safety strategy that includes standardized labeling procedures, positive patient identification, employee training, quality controls, workflow monitoring, and appropriate human oversight.
What is pathology specimen tracking?
Pathology specimen tracking maintains traceability between the patient, original specimen, containers, cassettes, tissue blocks, slides, tests, images, results, and final pathology report. An advanced anatomic pathology LIS can maintain these relationships electronically throughout the case lifecycle.
What should laboratories look for in specimen tracking software?
Laboratories should consider LIS systems with sample tracking that supports unique identifiers, barcode scanning, end-to-end specimen traceability, chain-of-custody documentation, automated workflow rules, exception management, audit trails, real-time status visibility, and integration with instruments, EHRs, and other laboratory software systems.
Why is specimen identification important for patient safety?
Laboratory results can directly influence diagnoses, surgeries, medications, and other treatments. Maintaining accurate specimen identification helps ensure that test results remain connected to the correct patient throughout the diagnostic process.
