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Julia died of unexplained post-operative complications. Her autopsy, and additional testing, suggested that the correct diagnosis was Epstein-Barr virus infection with acalculous cholecystitis. The correct diagnosis might have been considered had more attention been paid to her presenting symptoms, and a striking degree of lymphocytosis that was repeatedly demonstrated. The case illustrates how cognitive \u201cbiases\u201d can contribute to harm from diagnostic error. The case has profoundly impacted the involved healthcare organization, and Julia\u2019s parents have become leaders in helping advance awareness and education about diagnostic error and its prevention.<\/jats:p>","DOI":"10.1515\/dx-2018-0067","type":"journal-article","created":{"date-parts":[[2018,11,14]],"date-time":"2018-11-14T04:28:47Z","timestamp":1542169727000},"page":"257-266","source":"Crossref","is-referenced-by-count":8,"title":["Learning from tragedy: the Julia Berg story"],"prefix":"10.1515","volume":"5","author":[{"given":"Mark L.","family":"Graber","sequence":"first","affiliation":[{"name":"Society to Improve Diagnosis in Medicine , 5 Hitching Post , Plymouth, MA 02360 , USA"},{"name":"Senior Fellow, RTI International , Plymouth, MA , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dan","family":"Berg","sequence":"additional","affiliation":[{"name":"Minneapolis, MN , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Welcome","family":"Jerde","sequence":"additional","affiliation":[{"name":"Minneapolis, MN , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Phillip","family":"Kibort","sequence":"additional","affiliation":[{"name":"Children\u2019s Hospitals and Clinics of Minnesota , Minnetonka, MN , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrew P.J.","family":"Olson","sequence":"additional","affiliation":[{"name":"Department of Medicine , University of Minnesota Medical School , Minneapolis, MN , USA"},{"name":"Department of Pediatrics , University of Minnesota Medical School , Minneapolis, MN , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vinita","family":"Parkash","sequence":"additional","affiliation":[{"name":"Department of Pathology , Yale School of Medicine , New Haven, CT , USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"374","published-online":{"date-parts":[[2018,11,14]]},"reference":[{"key":"2025121207225828184_j_dx-2018-0067_ref_001_w2aab3b7c36b1b6b1ab2b1b1Aa","doi-asserted-by":"crossref","unstructured":"Makary M. 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