Learning from tragedy: the Julia Berg story

Diagnosis

Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / McDonald, Kathryn / Singh, Hardeep

Mark L. Graber Dan Berg Welcome Jerde Phillip Kibort Andrew P.J. Olson Vinita Parkash
Published Online: 2018-11-14 | DOI: https://doi.org/10.1515/dx-2018-0067

Abstract

This is a case report involving diagnostic errors that resulted in the death of a 15-year-old girl, and commentaries on the case from her parents and involved providers. Julia Berg presented with fatigue, fevers, sore throat and right sided flank pain. Based on a computed tomography (CT) scan that identified an abnormal-appearing gall bladder, and markedly elevated bilirubin and “liver function tests”, she was hospitalized and ultimately underwent surgery for suspected cholecystitis and/or cholangitis. 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 “biases” can contribute to harm from diagnostic error.
The case has profoundly impacted the involved healthcare organization, and Julia’s parents have become leaders in helping advance awareness and education about diagnostic error and its prevention.

Keywords: diagnostic error; Epstein-Barr viral infection

Introduction

Medical errors have been implicated as the third leading cause of death in the US [1], and diagnostic errors account for many of these [2], [3]. Diagnostic errors result from complex interactions between health care systems, providers and patients and are almost always caused by multiple factors. Previous studies have shown that most diagnostic errors result from a combination of systems and cognitive factors, often resulting in patient harm.

One of the most important responses when diagnostic errors occur is to formally analyze cases to determine why the error occurred and implement effective feedback for providers and systems to avoid similar errors in the future. This is the key to developing expertise for providers and is a nearly universal desire of patients and their families who have been harmed by diagnostic error. Here we share the story of Julia Berg, the diagnostic error that contributed to her death, and how providers, learners and systems continue to learn from Julia’s story.

Case presentation

The parent’s perspective (Dan Berg and Welcome Jerde)

Perspective of the hospital: Philip Kibort

Discussion

Trying to understand the diagnostic error

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Corresponding author: Mark L. Graber, MD, FACP, President, Society to Improve Diagnosis in Medicine, 5 Hitching Post, Plymouth, MA 02360, USA; and Senior Fellow, RTI International, Plymouth, MA, USA, Phone: +919 990-8497


Received: 2018-08-09

Accepted: 2018-10-22

Published Online: 2018-11-14

Published in Print: 2018-11-27


Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: None declared.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


Citation Information: Diagnosis, Volume 5, Issue 4, Pages 257–266, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2018-0067.

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