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1.
Nurs Educ Perspect ; 41(1): 57-58, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31860492

RESUMO

Considered the norm in multiple academic settings, simulation provided a low-risk, transformational clinical learning environment across programs at a college of nursing. Undergraduate nursing students received feedback from practicing nurses, whereas graduate nursing students honed skills in evaluative feedback and communication. This intraprofessional learning opportunity cultivated a rich learning environment. Feedback revealed that the learning milieu was permeated with opportunities needed for skills, competencies, and leadership development. Focusing on the concept of root cause analysis, this experience provided nurse administration students with hands-on exposure that would ultimately lead to developing competencies needed for roles in nursing leadership.


Assuntos
Bacharelado em Enfermagem , Análise de Causa Fundamental , Treinamento por Simulação , Humanos , Liderança , Estudantes de Enfermagem
2.
Crit Care Nurse ; 39(4): 29-38, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31371365

RESUMO

BACKGROUND: Successful blood glucose control is associated with improved outcomes of critically ill patients. However, insulin treatment can cause hypoglycemia, an important patient safety concern. The Joint Commission has recommended that all episodes of hypoglycemia be evaluated with a root cause analysis. OBJECTIVE: To reduce episodes of hypoglycemia through the analysis of data related to each episode. METHODS: The interdisciplinary team of the 16-bed critical care unit of a university-affilited teaching hospital developed a process to analyze, in real time, each episode of hypoglycemia (blood glucose level <60 mg/dL), including evaluation of patient risk factors and nursing interventions. The nursing staff integrated the root cause analysis into daily practice. The preimplementation period encompassed 2429 consecutive admissions, and the implementation period encompassed 2608 consecutive admissions. RESULTS: The percentage of patients with hypoglycemia decreased substantially during the implementation period among those without (from 6.15% to 3.78%; P = .001) and with diabetes (from 13.14% to 7.23%; P = .002). Mean blood glucose level decreased during the implementation period among patients without diabetes (P < .001), and did not change significantly among patients with diabetes (P = .23). The coefficient of variation, reflecting glucose variability, decreased during the implementation period among patients without and with diabetes (P < .001 for each). CONCLUSION: The nurse-driven root cause analysis was associated with a substantial reduction in hypoglycemia, with concomitant decreases in mean blood glucose level among patients without diabetes and glucose variability in patients without and with diabetes.


Assuntos
Glicemia/análise , Enfermagem de Cuidados Críticos/educação , Enfermagem de Cuidados Críticos/normas , Estado Terminal/enfermagem , Hipoglicemia/tratamento farmacológico , Hipoglicemiantes/normas , Hipoglicemiantes/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Currículo , Educação Continuada em Enfermagem , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque , Guias de Prática Clínica como Assunto , Análise de Causa Fundamental
3.
Stud Health Technol Inform ; 265: 101-106, 2019 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-31431584

RESUMO

Medication errors are preventable adverse events or unsafe conditions caused by inappropriate uses of medication. To collect data of patient safety events (PSE) and to analyze the root causes of PSE, reporting systems have been implemented in healthcare settings and patient safety organizations (PSO). However, the poor data quality of reports impedes the reporting and root cause analysis (RCA) of PSE. Incomplete or missing data is the most prevalent problem in event reports. To assess the data quality of PSE reports, we used an adapted taxonomy as the data evaluation model to evaluate the quality of narrative reports collected by a PSO. Sample reports were extracted based on eight error types and scored by experts. Most structured fields in the reports were ignored by reporters. In contrast, the narrative parts of the reports contain rich and valuable information. The evaluation results show that the adapted taxonomy is a promising tool for report quality assessment and improvement.


Assuntos
Confiabilidade dos Dados , Erros de Medicação , Humanos , Narração , Segurança do Paciente , Análise de Causa Fundamental
4.
BMC Health Serv Res ; 19(1): 583, 2019 Aug 19.
Artigo em Inglês | MEDLINE | ID: mdl-31426786

RESUMO

BACKGROUND: Medication safety in cancer patients receiving complex medication regimens is an important problem in various settings. Medication related events, interceptions and interventions are not well described in this area. We intended to study incidence, types, settings and stages involved, root cause analysis, medication classes involved and the level of harm cause by medication errors in two hospitals providing oncology services comparatively. The severity of incidents and interventions are studied. METHODS: It was a prospective cross sectional study among cancer in-patients of two tertiary care hospitals of KPK. Scale by NCC-MERP was used for evaluation of all medication related incidents. The data obtained was analyzed by IBM SPSS statistics 22 with 95% confidence interval and used the same for other descriptive statistics. RESULTS: All medication orders were reviewed at both sites (Computerized Prescription Order Entry and HWP systems). Potential ADEs incidence was found high at site 2 (97.5%) while medication errors without harm was high at site 1 (97.5%). Most events occur at prescribing level 87.6 and 81.7% at both sites 1 and 2. Types highly reported involved improper dose 31.4 and 15.5%, monitoring error 14.6 and 15.2% at site 1 and 2. Medications involved in these incidents were antibiotics 44 and 12.7%, antiemetic 7.5 and 15.8% and antineoplastic 2.9 and 9.4% at site 1 and 2. Severity of 3.6 and 36.5% incidents had potential to cause harm at site 1 and 2. Root causes were human factors 62.6 and 72.3%, drug selection 33.6 and 38.8%, and dose selection 39.6 and 15.3% at sites 1 and 2. Contributing factors including staff training 33.6 and 24.3%, system for covering patient care 14.9 and 36.6%, communication system 2.4 and 20.3%, interruptions 9.7 and 7.3% and others 78.8 and 68.6% were highly reported. Preventability of medication errors was 99% at both sites. Intervention was taken in 90.5% events at site 1 (CPOE system) while the incidence lowest at site 2 (HWP system). CONCLUSION: Medication related events are high among cancer in-patients at the site lacking updated electronic system for medication prescribing. Proper training about medication safety, reporting and interventions are required.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Erros de Medicação/estatística & dados numéricos , Neoplasias/tratamento farmacológico , Antibacterianos/efeitos adversos , Antieméticos/efeitos adversos , Antineoplásicos/efeitos adversos , Estudos Transversais , Prescrições de Medicamentos , Humanos , Incidência , Paquistão , Estudos Prospectivos , Análise de Causa Fundamental , Centros de Atenção Terciária/estatística & dados numéricos
5.
J Wound Ostomy Continence Nurs ; 46(4): 298-304, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31274857

RESUMO

Root cause analysis (RCA) is a systematic process for identifying the causes of an adverse occurrence or combined with an approach for a response designed to prevent recurrences. This method may be used for continuous quality improvement in a facility or health system. Root cause analysis can aid nurses and hospital risk managers to determine how the system can improve to reduce the number and severity of pressure injuries. The process of RCA begins with being certain the wound is a pressure injury using differential diagnoses of similar appearing skin disease and injury, followed by an examination of the processes of care (human roots) for missed actions or inactions that are linked to development of a particular pressure injury. The final step of RCA is a critical examination of the system (including people and processes) to look for modifiable trends or patterns are identified that are used to prevent recurrences.


Assuntos
Lesão por Pressão/etiologia , Análise de Causa Fundamental/métodos , Feminino , Humanos , Doença Iatrogênica/epidemiologia , Pessoa de Meia-Idade , Lesão por Pressão/classificação , Lesão por Pressão/epidemiologia , Melhoria de Qualidade , Análise de Causa Fundamental/classificação , Estados Unidos/epidemiologia
6.
Ig Sanita Pubbl ; 75(1): 11-28, 2019.
Artigo em Italiano | MEDLINE | ID: mdl-31185488

RESUMO

A Surgical Suite (SS) is a complex system in which different healthcare professionals work. Inefficient management could lead to waste of money and time and reduce quality of care. The aim of the study was to carry out an organizational assessment of a SS in northern Italy, in order to identify weaknesses and inadequacies related to its performance and promote strategies to increase efficiency. The study was conducted by process mapping of the working context, qualitative and quantitative analysis of patient documents and an evaluation of the critical issues using the root cause analysis (RCA) tool. The Plan Do Check Act (PDCA) method was used to implement the necessary changes. A detailed description of the staff involved, medical devices available, organization and timing of the SS was performed. Inefficiencies in the unit were caused mainly by insufficient medical devices and underusage of the radiological software Picture Archiving and Communication System (PACS). Root causes of inefficiencies were identified and classified into four areas: organization/structure, personnel, technologies and methods. In particular, critical issues were identified in: the planning processes, the heterogeneity of technical and Information technology skills and educational background of nursing staff, the presence of several computerized information systems and lack of a connection interface between the different software, the lack of internal procedures and paths and lack of continuing professional education opportunities. Two multidisciplinary working tables were launched by the hospital management in order to identify improvement strategies. The evaluation allowed us to define the root causes of SS inefficiency in this hospital, leading to a reorganization with a view to continuous improvement. An innovative aspect of the present study was the use of RCA to perform an organizational assessment in healthcare, rather than as a reactive risk management tool.


Assuntos
Assistência à Saúde/normas , Hospitais , Análise de Causa Fundamental , Centro Cirúrgico Hospitalar/normas , Pessoal de Saúde , Humanos , Itália
7.
Artigo em Inglês | PAHO-IRIS | ID: phr-50996

RESUMO

[EXCERPT]. Analyzing the causes of unsafe care can reduce the number of ‘near misses’ (incidents that may cause harm to patients) and adverse events (that actually produce harm). This is an important mandate for health care organizations committed to providing a safe environment for patients. Although guaranteeing absolute safety in all interventions is not always possible, hospitals and other health care institutions implement safety practices and surveillance methods to understand how these unsafe incidents occur. In many cases, these incidents were not generated by a single cause; and remote causes are as significant as more proximate ones...


Assuntos
Pacientes , Análise de Causa Fundamental , Medicina Preventiva , Saúde Pública , Segurança
9.
Artigo em Inglês | MEDLINE | ID: mdl-31071763

RESUMO

Doctor of Physical Therapy preparation requires extensive time in precepted clinical education which involves multiple stakeholders. Student outcomes in clinical education are impacted by many factors, and, in the case of failure, it can be challenging to determine which factors played a primary role in the poor result. Using existing root-cause analysis processes, the authors developed and implemented a framework designed to identify the causes of student clinical education failure. The framework, when applied to a specific student failure event, identified specific factors that contributed to the situation and revealed opportunities for improvement in both the clinical and academic environments. A root-cause analysis framework can help to drive change at the programmatic level, and future studies should focus on the framework's application to a variety of clinical and didactic settings.


Assuntos
Fracasso Acadêmico/psicologia , Aprendizagem , Fisioterapia/educação , Análise de Causa Fundamental , Estudantes , Competência Clínica/normas , Humanos , Estados Unidos
10.
Curr Pharm Biotechnol ; 20(8): 609-614, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30961484

RESUMO

OBJECTIVE: Catheter-related bloodstream infections (CRBSIs) pathogenesis is complex and multifactorial mostly due to cutaneous microorganisms migration through the catheter insertion site and catheter tip colonization. Ochrobactrum anthropi is a gram-negative bacterium belonging to the Brucellaceae and related infections are especially observed in immunocompromised patients. METHODS: Therefore, O. anthropi infection prevention and surveillance are relevant issues for healthcare system and risk management, in order to improve healthcare quality and patient safety. Four cases of anthropi-related CRBSIs occurring in immunodepressed patients under chemotherapy treatment are reported and the possible prevention and surveillance strategies are analyzed. RESULTS: In the reported cases, all infections occurred almost simultaneously in the Oncology Unit, leading to hypothesize an identical infection source. Subsequently, a clinical audit was performed in order to investigate infection origin and implement prevention and control strategies. Clinical audit allowed to identify the hand hygiene defects as the primary source of the infections, responsible for catheter flushing solution contamination. CONCLUSION: The aim of this study is to reveal how through correct root cause analysis and clinical audit, several measures could be undertaken in order to promote the prevention of the CRBSIs risk.


Assuntos
Bacteriemia/tratamento farmacológico , Infecções Relacionadas a Cateter/tratamento farmacológico , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Ochrobactrum anthropi/isolamento & purificação , Idoso , Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Bacteriemia/microbiologia , Bacteriemia/prevenção & controle , Infecções Relacionadas a Cateter/microbiologia , Infecções Relacionadas a Cateter/prevenção & controle , Feminino , Infecções por Bactérias Gram-Negativas/microbiologia , Infecções por Bactérias Gram-Negativas/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Ochrobactrum anthropi/efeitos dos fármacos , Guias de Prática Clínica como Assunto , Análise de Causa Fundamental
12.
Disaster Med Public Health Prep ; 13(2): 368-371, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-29716663

RESUMO

Six cases of serogroup C invasive meningococcal disease were identified in Treviso district, Veneto region, Italy between December 13 and 15, 2007. The afflicted patients were found to have attended the same Latin-dance clubs on the same nights, and chemoprophylaxis was provided to potentially exposed individuals. Despite these efforts, 2 cases caused by the same meningococcal strain subsequently occurred in the same area, without any apparent epidemiological correlation to the initial cases. This may have resulted from a failure to neutralize the meningococcal carrier/s. The root cause analysis method applied to public health emergency preparedness was used to analyze the response to this critical incident. The root cause analysis revealed a need to develop regional guidelines for the classification and management of a meningococcal outbreak and for developing risk-communication strategies that include the identification of appropriate channels of communication for differing segments of the population. (Disaster Med Public Health Preparedness. 2019;13:368-371).


Assuntos
Epidemiologia/instrumentação , Incerteza , Adulto , Quimioprevenção/métodos , Planejamento em Desastres/métodos , Surtos de Doenças/prevenção & controle , Epidemiologia/normas , Feminino , Humanos , Itália/epidemiologia , Masculino , Meningite/epidemiologia , Análise de Causa Fundamental
13.
Int J Qual Health Care ; 31(2): 110-116, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-29788153

RESUMO

OBJECTIVE: To examine if clustering of root causes of sentinel events (SEs) can contribute to organisational improvement of healthcare and patient safety by providing insight into organisational risk factors, patterns and trends. DESIGN: Retrospective, cross-sectional review of SEs from a hospital database reported to the Board of directors in 2016. SETTING: A regional teaching hospital in the Netherlands. INTERVENTION(S): Clustering of characteristics and variables of SEs to establish vulnerabilities and patterns of failure factors of the organisation. MAIN OUTCOME MEASURE(S): Characteristics and contributory causes of failure of SEs identified via root cause analysis (RCA). Outcomes reported using descriptive statistics. RESULTS: A total of 21 events were included involving 21 patients. Mean age was 56.7 years (SD 24.4), 71.4% were above 50 years of age. In 81.8%, the care was multi-disciplinary and in 76.2% the event resulted in permanent harm or injury. Of the 132 identified contributory root causes, most were related to human factors (53.8%) and organisational factors (40.2%). Technical and patient-related factors were identified in 3.0%. Organisational improvement strategies focused on the care of elderly patients, patients subjected to multi-disciplinary care and on improving knowledge, protocols and coordination of care. CONCLUSION: Clustering variables of SEs and contributory factors of failure through RCA helps to delineate a hospital-specific profile by providing a detailed insight into risk factors, patterns and trends in an organisation and to determine the best strategies for improvement by drawing lessons across events.


Assuntos
Erros Médicos/estatística & dados numéricos , Segurança do Paciente/normas , Gestão da Segurança/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Administração Hospitalar/métodos , Hospitais de Ensino/organização & administração , Humanos , Lactente , Masculino , Erros Médicos/mortalidade , Pessoa de Meia-Idade , Países Baixos , Estudos Retrospectivos , Análise de Causa Fundamental/métodos
14.
J Child Sex Abus ; 28(2): 187-199, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30188255

RESUMO

Significant progress has been made in the past two decades understanding how child molesters gain access to children and molest them while manipulating others to not get caught. However, incidents of child sexual abuse in schools by educators, and by other children, continue. This manuscript suggests that a comprehensive solution involves two components: (1) using root cause analysis methodology to systematically identify and integrate repetitive causes; (2) to use the findings from voluminous occupational safety research focusing on low-frequency but high-intensity events. Additionally, this manuscript describes eight organizational operations and practices that may reduce the risk of sexual abuse of children by educators or peers in a school setting. These findings were based on existing recommendations and on root cause analysis of thousands of incidents in schools and other youth serving organizations. Finally, the manuscript discusses how a framework drawn from occupational safety research can help schools and other youth serving organizations create environments that will help to create safe environments. Authors have used both components in working with thousands of organizations including faith-based, independent, and urban independent school districts, youth development programs, social service agencies, camps and so on serving diverse populations in 11 countries.


Assuntos
Abuso Sexual na Infância/prevenção & controle , Saúde do Trabalhador , Análise de Causa Fundamental , Instituições Acadêmicas , Adolescente , Adulto , Criança , Humanos
15.
J Emerg Nurs ; 45(3): 257-264, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30268339

RESUMO

PROBLEM: Although hospital falls and injuries are a significant patient safety concern, research is limited regarding falls and injuries in the emergency department. The purpose of this quality improvement project is to identify and implement evidence-based interventions to prevent patient falls and injuries in the emergency department. METHODS: Literature was reviewed to identify best practices for fall prevention in the emergency department. Data sources included Journal Storage, PubMed, Cumulative Index for Nursing and Allied Health Literature, and Cochrane Database of Systematic Reviews. A retrospective chart review and root cause analysis was completed on fall-related risk reports over a 19-month period at a specific emergency department. Multifactorial fall prevention interventions were implemented in March 2017, which included nursing educational sessions, patient education handout, and high-fall-risk patient identification signs. RESULTS: Post-implementation, zero falls were sustained in April 2017. The average number of falls between April and December 2017 was 5.2 falls/month. Completion of the fall-risk assessment tool ranged between 47 to 90 percent. The patient education handout was provided up to 40 percent of the time. The use of fall risk signs outside patient rooms occurred up to 43 percent of the time. DISCUSSION: The emergency department is a unique environment with complex patient populations. Multifactorial interventions should be used to identify and prevent patient falls and injuries. Multiple change strategies and leadership support are essential to sustain changes. Future research should be conducted regarding the use of fall risk assessments and fall prevention strategies specific to the emergency department.


Assuntos
Prevenção de Acidentes/normas , Acidentes por Quedas/prevenção & controle , Serviço Hospitalar de Emergência/normas , Segurança do Paciente/normas , Melhoria de Qualidade , Ferimentos e Lesões/prevenção & controle , Feminino , Humanos , Masculino , Michigan , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Análise de Causa Fundamental
16.
Bioprocess Biosyst Eng ; 42(2): 245-256, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30377782

RESUMO

Root cause analysis (RCA) is one of the most prominent tools used to comprehensively evaluate a biopharmaceutical production process. Despite of its widespread use in industry, the Food and Drug Administration has observed a lot of unsuitable approaches for RCAs within the last years. The reasons for those unsuitable approaches are the use of incorrect variables during the analysis and the lack in process understanding, which impede correct model interpretation. Two major approaches to perform RCAs are currently dominating the chemical and pharmaceutical industry: raw data analysis and feature-based approach. Both techniques are shown to be able to identify the significant variables causing the variance of the response. Although they are different in data unfolding, the same tools as principal component analysis and partial least square regression are used in both concepts. Within this article we demonstrate the strength and weaknesses of both approaches. We proved that a fusion of both results in a comprehensive and effective workflow, which not only increases better process understanding. We demonstrate this workflow along with an example. Hence, the presented workflow allows to save analysis time and to reduce the effort of data mining by easy detection of the most important variables within the given dataset. Subsequently, the final obtained process knowledge can be translated into new hypotheses, which can be tested experimentally and thereby lead to effectively improving process robustness.


Assuntos
Ciência de Dados/métodos , Indústria Farmacêutica/tendências , Análise de Causa Fundamental , Fluxo de Trabalho , Animais , Reatores Biológicos , Fermentação , Análise Multivariada , Poliovirus , Análise de Componente Principal , Análise de Regressão , Software , Células Vero
18.
Semin Thorac Cardiovasc Surg ; 31(3): 394-396, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30578828

RESUMO

Cognitive workload data of members of the cardiac surgery team can be measured intraoperatively and stored for later analysis. We present a case of a near-miss (medication error) that underwent root cause analysis using workload data. Heart rate variability data, representing workload levels, were collected from the attending surgeon, attending anesthesiologist, and lead perfusionist using wireless heart rate monitors. An episode of cognitive overload of the anesthesiologist due to a distractor was associated with the preventable error. Additional studies are needed to better understand the role of psychophysiological data in enhancing surgical patient safety.


Assuntos
Anestesistas/psicologia , Cognição , Ponte de Artéria Coronária/efeitos adversos , Erros de Medicação/prevenção & controle , Near Miss , Equipe de Assistência ao Paciente , Carga de Trabalho , Administração Intravenosa , Competência Clínica , Frequência Cardíaca , Antagonistas de Heparina/administração & dosagem , Antagonistas de Heparina/efeitos adversos , Humanos , Protaminas/administração & dosagem , Protaminas/efeitos adversos , Medição de Risco , Fatores de Risco , Análise de Causa Fundamental
19.
Int J Obstet Anesth ; 36: 17-27, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30392650

RESUMO

BACKGROUND: Post-dural puncture headache following trauma to the dural membrane during neuraxial anaesthesia occurs in 0.13-6.5% of pregnant patients. Identifying factors beyond individual performance that contribute to this adverse event is crucial to developing improvement strategies. METHODS: We used a root cause analysis framework, in a nested case-control study, to identify associated factors. Cases were all patients who had a post-dural puncture headache requiring an epidural blood patch. These patients were matched to a random group of control patients without post-dural puncture headache or known dural injury. Mixed logistic modelling was used. RESULTS: Within a dataset of 35 763 patients, we selected all 154 patients with post-dural puncture headache and compared them with 616 controls. Migraine (odds ratio [OR] 10.60, 95% CI 2.74 to 41.05), obstetric and perinatal pathology (OR 10.85, 95% CI 4.29 to 21.42), and multiple insertion attempts (OR 11.48, 95% CI 6.29 to 20.94), increased the risk of post-dural puncture headache. In contrast, training >3 years (OR 0.20, 95% CI 0.55 to 0.76) and a nurse anaesthetist present during the procedure (OR 0.05, 95% CI 0.01 to 0.29) decreased the risk. The anaesthetist's identity, the size of the labour room, the timing of the procedure or workload did not modify the risk. CONCLUSION: Post-dural puncture headache in this setting is not the result of the individual anaesthetist's characteristics alone. Additional factors including team composition, the presence of obstetrical perinatal pathology, and associated patient's conditions, are also associated with this event. Improvement strategies should consider all these factors.


Assuntos
Anestesia Epidural/efeitos adversos , Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cefaleia Pós-Punção Dural/epidemiologia , Complicações na Gravidez/epidemiologia , Análise de Causa Fundamental/estatística & dados numéricos , Adulto , Placa de Sangue Epidural , Estudos de Casos e Controles , Comorbidade , Dura-Máter , Feminino , Humanos , Transtornos de Enxaqueca/epidemiologia , Cefaleia Pós-Punção Dural/terapia , Gravidez , Fatores de Risco , Análise de Causa Fundamental/métodos , Suíça/epidemiologia
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