A woman had her breast removed in error after being wrongly diagnosed with cancer.
The woman's results were switched with those of another woman, who was later told she had cancer when the botch up was identified, the Herald on Sunday reported.
Both of the women, who are from the Otago region but have not been named, had biopsies tested with Southern Community Laboratories after mammograms revealed suspicious lesions.
After being diagnosed with cancer one of the woman had a breast removed while the other was told she did not have cancer.
The pair were later told that their results had been switched.
A review of testing is under way at Southern District Health Board (SDHB), which already faces criticism over delays in diagnosing breast cancer in 28 women between 2007 and 2010.
Michael Landmann, lead surgeon of the SDHB's BreastScreen Aotearoa programme, said the error was unusual and said testing was normally a safe and accurate process.
"[The review] will come up with a result that will change something in pathology, such as how the labels are stuck on, or something like that," he said.
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