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 Table of Contents  
Year : 2023  |  Volume : 3  |  Issue : 2  |  Page : 314-316

Hard cataract or heart attack: A tragic miscommunication recipe!

1 Department of Ophthalmology, Command Hospital, Lucknow, Uttar Pradesh, India
2 Anterior Segment and Cornea Services, Department of Ophthalmology, Command Hospital, Lucknow, Uttar Pradesh, India
3 Department of Ophthalmology, Military Hospital, Bathinda, Punjab, India

Date of Submission10-Nov-2022
Date of Acceptance03-Jan-2023
Date of Web Publication28-Apr-2023

Correspondence Address:
Rakesh Kumar Jha
Department of Ophthalmology, Command Hospital, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2976_22

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Miscommunication arises when interacting members connect, but one or more of its members in the communication chain does not fully understand what has been conveyed. This can happen for a variety of reasons, including the initiator's inappropriate word selection, existence of communication barrier between the initiator and receiver, the receiver's misperception, and less frequently, the receiver being “off-target” to the communication chain. This case involves a 54-year-old woman with no known comorbid conditions who experienced an acute panic attack just before the start of scheduled cataract surgery, which was managed with abandonment of surgery followed by monitoring and treatment in the intensive care, conducting the departmental root cause analysis, and subsequent performance of uneventful surgery with satisfactory outcome after addressing the root cause.

Keywords: Communication, hard cataract, miscommunication, off-target receiver

How to cite this article:
Jha RK, Kaushik J, Singh A. Hard cataract or heart attack: A tragic miscommunication recipe!. Indian J Ophthalmol Case Rep 2023;3:314-6

How to cite this URL:
Jha RK, Kaushik J, Singh A. Hard cataract or heart attack: A tragic miscommunication recipe!. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 1];3:314-6. Available from: https://www.ijoreports.in/text.asp?2023/3/2/314/375008

Communication happens when one mind acts upon its environment in order to transmit its own experience to another mind, which share a common set of semiotic rules, either by speaking, writing, or using some other medium. It is a continuous process which primarily involves four key elements, namely, sender, message, channel, and receiver.[1] The person who initiates a message is called the “sender,” and the one to whom the message is directed is called the “receiver,” usually known as the listener, reader, viewer, or audience. An effective message is one that is received and decoded by the target receiver in the way that the sender intended, which, in turn, depends on his/her knowledge of the subject matter of the message, experience, trust, and relationship with the sender.[2] The commonest mode or channel for the transmission of messages in the communication process is the auditory words, which initiate specific biological responses like fight or flight responses in the receiver.

For successful communication, the receiver needs to be on the same level as of the sender; otherwise, even though the receiver may receive messages, he/she may not be able to interpret its meaning.[2] Moreover, sometimes, these messages can also generate miscommunication along with unintended consequences, such as when the intended or target receiver does not react as the sender anticipated or when the message reaches unintended or “off-target receivers.”[1] The off-target receiver is the person or a group of people whose behavior is influenced without the intention of sender.

In today's health-care system, patients are frequently handed over to different caregivers at different locations, requiring effective communication of vital information.[3] Miscommunication at any step in this communication chain can lead to serious negative consequences among patients, ranging from delayed treatment,[4] misdiagnosis,[4] medication errors,[4],[5] patient injury,[6],[7],[8],[9] to even death.[7],[8],[9]

Although there have been reports of miscommunication in medical settings,[4],[5],[6],[7],[8],[9] we were unable to locate any such case reports in the field of ophthalmology, and we believe this to be the first case report of miscommunication in this specialty. Additionally, in every example of reported miscommunication, the patient was the intended or the “target receiver” for the message sent by the sender, whereas in our case, the patient was an unintended or off-target receiver for the message sent by the sender in the communication chain during the communication process.

  Case Report Top

A 54-year-old female with no comorbid conditions reported to Command hospital, Lucknow in Jan 2022 with a 3-month history of gradual painless progressive diminution of vision in both eyes.

Clinical examination revealed best-corrected visual acuity of 20/120 (OD) and 20/80 (OS) with grade III nuclear sclerosis and unremarkable findings in the rest of anterior segment and fundus examination (OU). She was diagnosed as a case of senile cataract in both eyes and planned for cataract surgery after due preoperative counseling was given and consent was taken (right eye being first). She had previously undergone an uneventful cholecystectomy surgery under general anesthesia. She spoke coherently while maintaining a good eye contact along with pleasant demeanor. Her initial vital signs, pertinent systemic examination, and initial investigations, including an electrocardiogram (ECG), were all normal. The anesthesiologist found her to be in American Society of Anesthesiologists (ASA) Class 1 and fit for surgery during preoperative evaluation.

Patient underwent uncomplicated cataract surgery in the right eye by phacoemulsification technique under local anesthesia, which led to recovery of vision to 20/20 (OD) unaided at 4 weeks after surgery. Subsequently, cataract surgery for the left eye was worked up and planned as per the hospital protocol by another surgeon of the same center.

The patient was comfortable and had stable vital signs in the preoperative room on the scheduled day of surgery. The clinical reassessment, including monitoring of vital parameters for ascertaining fitness for initiation of surgery after she lied on the operative table, was unremarkable. Patient was planned for the cataract surgery by phacoemulsification technique under local anesthesia; however, after cleaning, anesthetizing, and draping, the operating surgeon assessed her cataract to be denser than grade III nuclear sclerosis and communicated to his assisting team to remain vigilant for specific assistance for the subject case, referring patient's denser sclerosis of cataract as “hard cataract.” Just before the initiation of first incision, the patient developed sudden shaking of all limbs along with chest discomfort, chills, tachycardia, raised blood pressure, and rapid respiration, but with maintained oxygen saturation. The patient was conscious and oriented but informed lack of control over the shaking of her limbs. She was given antianxiety and antihypertensive medications but continued to experience the aforesaid symptoms, following which the surgery was postponed. She was transferred to postoperative room, where she was managed under the care of anesthesiologist. After 1–2 h, her vitals got stabilized. Relevant clinical investigations, including serial ECG, tests for cardiac enzymes, sugar profile, and electrolytes, were unremarkable. She was monitored as an in-patient for 24 h, which revealed stabilized vital parameters along with abated symptoms. Electroencephalogram (EEG) and neuroimaging excluded seizure or intracranial organic pathology.

Subsequently, the case was evaluated by the departmental “root cause analysis,” which revealed that she underwent an acute panic attack as a result of inadvertently mishearing the operating surgeon's repeated usage of the phrase “hard cataract” as “heart attack.” Besides, tone of this particular word as heard was simulating anxiety among the communicating team, leading to her perception that perhaps the treating doctors have detected a fresh life-threatening heart attack on herself, to which she became abruptly apprehensive.

The patient was explained accordingly and cataract surgery was undertaken within 1 week after taking due care for this simple but vital entity. The surgery was uneventful, and the patient showed adequate visual recovery in the follow-up.

  Discussion Top

In the clinical settings, patients need to be communicated about difficult circumstances like guarded visual prognosis or surgical complications, which at times can be “heart breaking” for the patient. These discussions are viewed and responded by the patients based on their perspectives and level of literacy as well as the level of empathy, clarity, and optimism combined with realism, used in communication by the communicating surgeon.

In the discussed case, the standard treatment protocol along with medical knowledge was used with an intention to provide best care, but there was lack of recognition of the simple fact that the draped patient lying on the operative table was also a member of the ongoing communication.

This case emphasizes how crucial it is to continually be vigilant that the patient being operated upon is an off-target receiver and responder to any type of communication inside the operating room. Not recognizing this simple fact along with casual selection of words/phrases may trigger clinical or subclinical events, especially when there is a barrier to the communication, like in the case of elderly or illiterate patients. These events may range from undesirable changes in clinical or subclinical vital parameters to a life-threatening complication.

The miscommunication has been implicated as a common cause of avoidable disability or death in a retrospective Australian survey of hospital admissions.[10] Chassin and Becher[11] have reported how a wrong patient underwent an invasive procedure due to faulty exchange of information between care providers.

Even though, fortunately, everything turned out safely and satisfactorily in our instance, we believe that such events could have been avoided with better communication. Mastering the skill to effectively communicate with patients has been highlighted by Feinmann,[12] and we propose that it needs to be emphasized in the current medical education curriculum, besides teaching technical expertise.

In summary, this case report highlights the importance of recognizing the patient as an off-target receiver to any interactive communications in health-care areas, adherence to which may help to achieve improved patient's alliance during surgery or to the prescribed management plans.

  Conclusion Top

Patient in health-care areas is an off-target receiver to any professional communications held in his/her vicinity. Negligence of this fact, especially while performing surgery, can trigger heavy emotional ramifications and stress in the patient, leading to unavoidable complications. In order to improve outcomes and clientele satisfaction, it may be very useful to identify physician–patient communication as a clinical skill of core therapeutic significance. This is especially true given the wide range of cultural, literacy, and linguistic variations that exist in today's world.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Berlo DK. The Process of Communication: An Introduction to Theory and Practice. New York, Holt, Rinehart and Winston; 1960.  Back to cited text no. 1
Jandt FE. An Introduction to Intercultural Communication: Identities in a Global Community. 9th ed. SAGE Publications; 2017.  Back to cited text no. 2
Manias E, Geddes F, Watson B, Jones D, Della P. Communication failures during clinical handovers lead to a poor patient outcome: Lessons from a case report. Sage Open Med Case Rep 2015;3:2050313X15584859.  Back to cited text no. 3
Lee A, Mills PD, Neily J, Hemphill RR. Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. Joint Comm J Qual Patient Saf 2014;40:253-62.  Back to cited text no. 4
Bartlett G, Blais R, Tamblyn R, Clermont RJ, MacGibbon B. Impact of patient communication problems on the risk of preventable adverse events in acute care settings. CMAJ 2008;178:1555-62.  Back to cited text no. 5
Douglas RN, Stephens LS, Posner KL, Davies JM, Mincer SL, Burden AR, et al. Communication failures contributing to patient injury in anaesthesia malpractice claims. Br J Anaesth 2021;127:470-8.  Back to cited text no. 6
Najafpour Z, Jafary M, Saeedi M, Jeddian A, Adibi H. Effect size of contributory factors on adverse events: An analysis of RCA series in a teaching hospital. J Diabetes Metab Disord 2015;15:1-9.  Back to cited text no. 7
Tiwary A, Rimal A, Paudyal B, Sigdel KR, Basnyat B. Poor communication by health care professionals may lead to life-threatening complications: Examples from two case reports. Wellcome Open Res 2019;4:7.  Back to cited text no. 8
Sutcliffe, KM, Lewton E, Rosenthal MM. Communication failures: An insidious contributor to medical mishaps. Acad Med 2004;79:186-94.  Back to cited text no. 9
Wilson, RL, Runciman WB, Gibberd RW, Harrison BT, Newby L, et al. The quality in Australian health care study. Med J Aust 1995;163:458-71.  Back to cited text no. 10
Chassin MR, Becher EC. The wrong patient. Ann Intern Med 2002;136:826-33.  Back to cited text no. 11
Feinmann J. Brushing up on doctors communication skills. Lancet 2002;360:1572.  Back to cited text no. 12


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