Jaw-dropping medical mix-ups: 5 real cases that should make every doctor pause
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The surgeon proceeded with labeling the removed liver specimen as a 'spleen,' and it wasn’t until following the death that it was identified that the organ removed was actually Mr. Bryan’s liver, as opposed to the spleen.
—Joe Zarzaur, attorney
While medicine is built around redundancy, there are always the cases that make you wonder: How did that happen?
Some of the most unsettling medical errors aren’t obscure diagnostic misses—they’re basic mix-ups involving the wrong patient, the wrong specimen, the wrong medication, or even the wrong body part.
Related: 8 outrageous malpractice cases—and what physicians can learn from themAnd while these cases can be shocking—sometimes almost unbelievable—they’re also useful reminders that patient safety depends on more than individual vigilance. It depends on systems that make the wrong action difficult to take and the right action easy to verify.
Here are five recent cases worth knowing about.
1. A woman was told she had cancer, but the biopsy belonged to someone else
In August 2026, a Georgia woman sued Kaiser Permanente after what she says was a pathology labeling error led to an aggressive cancer diagnosis and an unnecessary hysterectomy.[]
Cassandra Barksdale had sought care in early 2025 for heavy bleeding and fibroids. She underwent a biopsy in March and was subsequently told that she had an aggressive form of endometrial uterine cancer.
According to her lawsuit, she underwent a full hysterectomy and was told she would receive instructions about chemotherapy.[] But the diagnosis was wrong.
Months later, DNA testing reportedly established that the tissue sample showing cancer belonged to another patient.
Kaiser acknowledged the error, saying Barksdale “should not have experienced” what happened and that it had taken steps to prevent a recurrence. The lawsuit alleges that the labeling mix-up resulted in the unnecessary surgery and substantial physical and emotional pain.[][]
2. The surgeon allegedly removed a liver instead of a spleen
On August 21, 2024, William Bryan, a 70-year-old Alabama man, underwent what was supposed to be a laparoscopic splenectomy in Florida.[]
According to prosecutors, surgeon Thomas Shaknovsky removed the patient’s liver instead of his spleen.
The patient suffered catastrophic blood loss and died on the operating table. The spleen remained in his body.
“Dr. Shaknovsky removed Mr. Bryan’s liver and, in so doing, transected the major vasculature supplying the liver, causing immediate and catastrophic blood loss resulting in death. The surgeon proceeded with labeling the removed liver specimen as a 'spleen,' and it wasn’t until following the death that it was identified that the organ removed was actually Mr. Bryan’s liver, as opposed to the spleen,” the family’s lawyer, Joe Zarzaur, said in the statement.[][]
Dr. Shaknovsky made a similar mistake in 2023, when he removed portions of a patient’s pancreas instead of an adrenal gland.[]
3. The wrong embryo was transferred, and a woman gave birth to another couple’s baby
In Australia, an IVF clinic acknowledged in 2025 that it had mistakenly transferred the wrong embryo into a woman’s uterus.[]
The woman subsequently gave birth to a baby who was genetically unrelated to her and her partner. The clinic described the incident as the result of “human error.” The clinic notified the affected families and became the subject of regulatory scrutiny.
A February 2026 Reuters investigation examined reports involving Johnson & Johnson’s TruDi navigation system, which uses software to help surgeons navigate anatomy during sinus procedures.[]
According to FDA adverse-event reports reviewed by Reuters, at least 100 malfunctions or adverse events involving the system were reported after AI capabilities were added, compared with only a handful of reports before the software change. At least 10 people were reported injured between late 2021 and November 2025.
Reported events included a cerebrospinal fluid leak, an alleged puncture of the skull base, and two cases in which patients reportedly suffered strokes after major arteries were injured.
“I think the FDA’s traditional approach to regulating medical devices is not up to the task of ensuring AI-enabled technologies are safe and effective. We’re relying on manufacturers to do a good job at putting products out. I don’t know what’s in place at the FDA represents meaningful guardrails,” Alexander Everhart, PhD, told Reuters.
The reports are not proof that the AI system caused the injuries. FDA device reports can be incomplete and aren’t designed to establish causation. The companies involved have also disputed or questioned the alleged connection.
5. 4 patients were given the wrong medication during surgery
In August 2026, four patients at Ascension Saint Thomas Midtown Hospital in Nashville, TN, were affected by a medication mix-up during joint-replacement procedures.[]
According to a Tennessee Health Facilities Commission report, the patients received potassium phosphate instead of mepivacaine, the local anesthetic that was intended.
One patient, 72-year-old Glenda Dorton, was reportedly left paralyzed from the chest down. Her family alleged that she received potassium rather than the intended anesthetic.[][] The hospital investigated the incident and reported it to regulators.
Related: AI and malpractice risk: Are you exposed?The common thread: Errors rarely happen in isolation
In each situation, there should have been—and presumably were supposed to be—multiple opportunities for verification. Here’s what doctors can learn from these cases:
1. Don’t dismiss a mismatch
When the clinical story doesn't fit the test result, don’t automatically force the clinical story to fit the test. A surprising pathology result deserves a closer look, particularly before an irreversible treatment.
2. Build verification around irreversible decisions
The closer a decision gets to irreversible, the more valuable redundancy becomes. A second look at a pathology specimen takes time.
Confirming anatomy before removing an organ takes time. Repeating a patient or medication identification check takes time. But compared with an unnecessary hysterectomy, organ removal, or administration of the wrong drug, it’s cheap insurance.
3. Don’t confuse automation with certainty
AI and other decision-support technologies can reduce workload and improve accuracy. But clinicians still need to understand what the system is actually doing—and what happens when it’s wrong.
A computer-generated answer isn’t inherently more trustworthy than a human-generated one.
4. Make stopping acceptable
Perhaps the most important safety tool in medicine remains the ability to say: “Something isn’t right. Let’s stop.”
That sentence shouldn’t require a junior clinician to challenge a senior surgeon, a nurse to question a medication order, or a pathologist to revisit a specimen. It should be built into the culture.