Missed Diagnosis Visceral Leishmaniasis: A Tragedy of Note Bloat

Key Takeaways

• Note bloat hides critical diagnostic clues
• Travel history omitted from early infectious notes
• No single physician led care coordination
• Premature immunosuppression worsened undiagnosed infection
• Delayed broad pathogen testing cost patient’s life

Summary

Louis‑Hunter Kean, a 34‑year‑old, died in November 2023 after a year of high fevers, organomegaly, and multiple hospitalizations. Although clinicians repeatedly noted “visceral leish” and ordered a PCR, the test was never completed and his travel to Tuscany was buried in the record. The case exposes how electronic health‑record note bloat, fragmented specialty care, and absent clinical leadership can mask life‑saving clues. It serves as a stark reminder that documentation overload can turn a curable disease into a fatal outcome.

Pulse Analysis

Electronic health‑record (EHR) note bloat has become a silent threat to patient safety. Studies such as the JAMA analysis reveal that over half of note content is copied‑and‑pasted, with duplication rates climbing from 33 % in 2015 to 54.2 % in 2020. This redundancy creates visual noise, making essential findings—like a travel exposure to leishmaniasis—easy to overlook. When clinicians read the same paragraph repeatedly, the information is perceived as already acted upon, eroding urgency and fostering false reassurance.

The Kean case also illustrates how fragmented multidisciplinary care amplifies diagnostic delay. Multiple specialties—rheumatology, hematology‑oncology, infectious disease, gastroenterology—each pursued their own differential without a designated care captain. Frequent handoffs and rotating teams are known to contribute to the majority of serious adverse events. In Kean’s trajectory, the lack of a single physician to verify test completion and synthesize findings allowed a critical PCR request to fall through the cracks, while premature immunosuppression for suspected HLH accelerated the underlying parasitic infection.

Addressing these failures requires both cultural and technical interventions. Health systems should enforce “note hygiene” policies that limit copy‑paste, promote concise documentation, and flag unresolved orders. Assigning a lead physician or case manager to complex patients ensures accountability for test follow‑up and multidisciplinary communication. Early involvement of infectious‑disease experts and rapid pathogen‑specific assays can further reduce diagnostic latency. By tightening documentation practices and clarifying leadership roles, hospitals can transform tragic oversights like Kean’s into preventable events, enhancing overall quality of care.