An independent report dealing with the removal of the wrong kidney from a patient at Crumlin Children's Hospital in Dublin has been published today.
The child at the centre of the case had a healthy kidney removed instead of a poorly functioning right kidney.
The error, which the hospital described as unprecedented, came to light in April of this year.
An independent review has since been carried out by Great Ormond Street Hospital for Children in London.
It concludes that there was no fail-safe system in place and the patient was not properly "marked" for surgery based on medical imaging.
The hospital says it accepts all the recommendations and will ensure they are implemented.
They include a review of radiology systems to upgrade to a system where images can be stored and viewed electronically.