I suppose as you have a 2 sample rule, and have only come across this once, then it is about being realistic on detecting the error. It would be far riskier to have to cross-match everything and the impact this would have on staff, stock holding etc would mean introducing other errors. I still don't understand how the result can be transferred to the incorrect LIMS record if the transfer between the analyser and LIMS requires a full lab number and possibly other identifier match- very difficult to replicate and investigate properly unless the supplier can provide more details.

Perhaps the wider user group has not come across this error yet as your lab probably tests far more samples?