Dear HIFA colleagues,
I am forwarding (a translation of) a message below from our HIFA-Spanish forum, and a comment from me. With thanks to Jackeline Alger (Honduras), HIFA-Spanish coordinator. https://www.hifa.org/forums/hifa-spanish
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"I would like to share my perspective from the clinical laboratory regarding cryptic parasitic infections. These are characterized by the difficulty of confirming a diagnosis when the parasite load is low and available tests have limited sensitivity. An example of this is leishmaniasis, caused by the *Leishmania* protozoan, which can present in various clinical forms depending on the species.
"This situation can be exacerbated in healthcare facilities facing high patient demand and limited resources. This creates constant concern regarding patient safety, as there is a real risk of overlooking infections; if unidentified, these infections do not receive appropriate treatment and can progress to serious complications. Faced with these diagnostic limitations, we have a professional commitment to seek strategies that increase diagnostic certainty and accuracy—such as using more sensitive methods, repeating tests, integrating clinical and epidemiological criteria, and maintaining close communication with medical staff—to ensure every patient has the best chance of timely identification and treatment.
"While all of the above can be implemented, in settings with high demand and limited resources, it becomes a challenge that can only be overcome through teamwork, both within and outside the clinical laboratory."
Jackeline
HIFA-Spanish Coordinator
HIFA-es Profile: Jackeline Alger, MD, PhD, is a physician and parasitologist. She is the Executive Director of the Antonio Vidal Institute of Infectious Diseases and Parasitology in Tegucigalpa, Honduras. She served as the HIFA Country Representative for the years 2015 and 2018. Email: jackelinealger AT gmail.com. Why did I join HIFA? https://www.youtube.com/watch?v=nuXED4xpLJk
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COMMENT (NPW): I note a parallel here with my experience as a junior hospital doctor with a child with epiglottitis. In both cases, it is recognised that it is often very difficult to make a diagnosis. In my case, I learned (40 years later!) that epiglottitis is missed at first presentation in about 80% of cases (if I had known this at the time, I would have felt much less self-blame over the past four decades). Jackeline describes difficulty in diagnosis of leishmaniasis because of the sensitivity of the test.
A missed diagnosis may be an example of unsafe care and/or it may be that the condition was difficult to recognise, and clinicians (or laboratory staff) followed appropriate processes but the diagnosis only became apparent later.
Therefore, in Jackeline's lab, a missed diagnosis of leishmaniasis may simply be a consequence of low sensitivity, in which case it would not normally be classified as 'unsafe care'. However, if the wrong test was carried out, or done inappropriately, or there was a reporting or interpretation error, then this would be classified as 'unsafe care'. In the case of the child with epiglottitis, I now recognise that it was not my 'missed diagnosis' in the A&E department that was the primary issue - it was the multiple systems factors that led to the tragic events of the subsequent 2 hours.
I hope other clinicians will be able to look back on their experiences and see how factors beyond their contol may have led to adverse outcomes. There is of course another group to consider: patient safety events whereby a single clinician has been largely or solely responsible. These events are uncommon but must be especially hard to bear.
Best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org