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Takhtinejad NJ, Stewart D, Nazar Z, Hamad A, Hadi MA. Identifying factors influencing clinicians' reporting of medication errors: a systematic review and qualitative evidence synthesis using the theoretical domains framework. Expert Opin Drug Saf 2024:1-12. [PMID: 39192820 DOI: 10.1080/14740338.2024.2396397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/08/2024] [Accepted: 08/14/2024] [Indexed: 08/29/2024]
Abstract
INTRODUCTION Medication errors have a significant impact on patient safety and professional practice. The widespread under-reporting of errors by clinicians indicates the critical need for behavioral change. This systematic review aimed to identify and synthesize qualitative evidence on factors influencing clinicians' reporting of medication errors. AREAS COVERED Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, PubMed, and Embase were searched until March 2023 for studies on factors influencing clinicians' reporting of medication errors. Two independent reviewers conducted the screening, data extraction, and quality appraisal. Using framework synthesis approach, the identified themes were mapped to Theoretical Domains Framework (TDF). EXPERT OPINION The review analyzed fourteen high-quality studies across various regions. Facilitators of reporting were identified in the TDF domains of beliefs about consequences knowledge and social/professional role and identity. More themes emerged as barriers, mapped to the domains of beliefs about consequences, emotions, environmental context and resources and knowledge. The review suggests aligning these barriers with key behavior change techniques, such as emphasizing the risks of non-reporting, promoting emotional well-being, improving accessibility of reporting systems and advancing knowledge through educational programs. Future work should focus on developing these behavior change techniques into practical interventions.
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Affiliation(s)
- Neda J Takhtinejad
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Zachariah Nazar
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Anas Hamad
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Muhammad A Hadi
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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Henry Basil J, Premakumar CM, Mhd Ali A, Mohd Tahir NA, Seman Z, Voo JYH, Ishak S, Mohamed Shah N. Prevalence and factors associated with medication administration errors in the neonatal intensive care unit: A multicentre, nationwide direct observational study. J Adv Nurs 2024. [PMID: 38803148 DOI: 10.1111/jan.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 04/29/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
AIM(S) To determine the prevalence of medication administration errors and identify factors associated with medication administration errors among neonates in the neonatal intensive care units. DESIGN Prospective direct observational study. METHODS The study was conducted in the neonatal intensive care units of five public hospitals in Malaysia from April 2022 to March 2023. The preparation and administration of medications were observed using a standardized data collection form followed by chart review. After data collection, error identification was independently performed by two clinical pharmacists. Multivariable logistic regression was used to identify factors associated with medication administration errors. RESULTS A total of 743 out of 1093 observed doses had at least one error, affecting 92.4% (157/170) neonates. The rate of medication administration errors was 68.0%. The top three most frequently occurring types of medication administration errors were wrong rate of administration (21.2%), wrong drug preparation (17.9%) and wrong dose (17.0%). Factors significantly associated with medication administration errors were medications administered intravenously, unavailability of a protocol, the number of prescribed medications, nursing experience, non-ventilated neonates and gestational age in weeks. CONCLUSION Medication administration errors among neonates in the neonatal intensive care units are still common. The intravenous route of administration, absence of a protocol, younger gestational age, non-ventilated neonates, higher number of medications prescribed and increased years of nursing experience were significantly associated with medication administration errors. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The findings of this study will enable the implementation of effective and sustainable interventions to target the factors identified in reducing medication administration errors among neonates in the neonatal intensive care unit. REPORTING METHOD We adhered to the STROBE checklist. PATIENT OR PUBLIC CONTRIBUTION An expert panel consisting of healthcare professionals was involved in the identification of independent variables.
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Affiliation(s)
- Josephine Henry Basil
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Chandini Menon Premakumar
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Adliah Mhd Ali
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Ain Mohd Tahir
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Zamtira Seman
- Sector for Biostatistics & Data Repository, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - James Yau Hon Voo
- Department of Pharmacy, Hospital Duchess of Kent, Ministry of Health Malaysia, Sabah, Malaysia
| | - Shareena Ishak
- Department of Pediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Noraida Mohamed Shah
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Mattiuzzi C, Plebani M, Lippi G. Recent mortality rates due to complications of medical and surgical care in the US. Diagnosis (Berl) 2024; 0:dx-2024-0071. [PMID: 38756092 DOI: 10.1515/dx-2024-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES Medical errors and complications pose a major threat to the safety of healthcare systems worldwide. This article was hence aimed at determining the current burden of complications of medical and surgical care in the US. METHODS We searched the latest version of the US Centers for Disease Control and Prevention (CDC) WONDER online database (years 2018-2022) using ICD-10 codes Y40-Y84 (complications of medical and surgical care). RESULTS The age-adjusted death rate for complications of medical and surgical care increased from 1.17 × 100,000 in 2018 to 1.49 × 100,000 in 2021, but then declined to 0.85 × 100,000 in 2022. The gender-specific analysis showed a similar trend, with the age-adjusted death rate values always being higher in men than in women. A clear age-dependent relationship was also found in the crude mortality rate for complications of medical and surgical care, as higher death rates were observed in older patients. CONCLUSIONS This analysis reveals that the burden of complications of medical and surgical care has increased over time, especially during the COVID-19 pandemic, but has then considerably declined in 2022. However, root cause analysis and actions are still needed for preventing the still noticeable consequences of medical complications.
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Affiliation(s)
- Camilla Mattiuzzi
- Medical Direction, Rovereto Hospital, Provincial Agency for Social and Sanitary Services (APSS), Trento, Italy
| | - Mario Plebani
- Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, 19051 University of Verona , Verona, Italy
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Chen Y, He Y, Wang P, Jiang F, Du Y, Cheung MY, Liu H, Liu Y, Liu T, Tang YL, Zhu J. The association between the adverse event reporting system and burnout and job satisfaction of nurses: Workplace violence as a mediator. Int Nurs Rev 2024. [PMID: 38650586 DOI: 10.1111/inr.12962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 02/25/2024] [Indexed: 04/25/2024]
Abstract
AIMS This study aims to explore the association between the implementation of the adverse event reporting system (AERS), burnout, and job satisfaction among psychiatric nurses, with a focus on examining the mediating effect of workplace violence from patients. BACKGROUND Many organizational and personal factors contribute to burnout and job satisfaction experienced by nurses. AERS, serving as a key component of organizational-level quality improvement system, impacts the overall workplace wellness of nurses. METHODS A national sample of 9,744 psychiatric nurses from 41 psychiatric hospitals across 29 provinces in China participated. Burnout was measured by the Maslach Burnout Inventory. Job satisfaction was measured using the Minnesota Satisfaction Questionnaire. Workplace violence was assessed by nurses' experience of verbal and physical violence. Multilevel linear regression analyses were carried out to examine if AERS impacts burnout and job satisfaction and to identify the mediating role of workplace violence. RESULTS AERS was positively associated with job satisfaction, but negatively with burnout and workplace violence. Workplace violence exhibited a positive association with burnout and a negative association with job satisfaction. Mediation analyses indicated that the associations between AERS, burnout, and job satisfaction were mediated by workplace violence. CONCLUSIONS The application of AERS is associated with a reduction in workplace violence in hospitals, which contributes to the diminished burnout and heightened job satisfaction among psychiatric nurses. IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY The study highlights the importance of organizational efforts and mechanisms in promoting nurses' well-being. It is necessary for hospital management to create a safe workplace through the implementation of AERS.
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Affiliation(s)
- Yanhua Chen
- Vanke School of Public Health, Tsinghua University, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Yanrong He
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Peicheng Wang
- Vanke School of Public Health, Tsinghua University, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Feng Jiang
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, China
- Institute of Healthy Yangtze River Delta, Shanghai Jiao Tong University, Shanghai, China
| | - Yanrong Du
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | | | - Huanzhong Liu
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China
- Anhui Psychiatric Center, Anhui Medical University, Hefei, China
| | - Yuanli Liu
- School of Health Policy and Management, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tingfang Liu
- Institute for Hospital Management, Tsinghua University, Beijing, China
| | - Yi-Lang Tang
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, Georgia, USA
- Addiction Psychiatry Fellowship Program, Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Jiming Zhu
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
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MacKay MM, Jordan KS, Powers K, Munn LT. Improving Reporting Culture Through Daily Safety Huddles. Qual Manag Health Care 2024; 33:105-111. [PMID: 37363817 DOI: 10.1097/qmh.0000000000000411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND OBJECTIVES A major obstacle to safer care is lack of error reporting, preventing the opportunity to learn from those events. On an acute care unit in a children's hospital in southeastern United States, error reporting and Survey for Patient Safety Culture (SOPS 1.0) scores fell short of agency benchmarks. The purpose of this quality improvement project was to implement a Safety Huddle Intervention to improve error reporting and SOPS 1.0 scores related to reporting. METHODS Marshall Ganz's Change through Public Narrative Framework guided creation of the project's intervention: A story of self, a story of us, a story of now. A scripted Safety Huddle was conducted on the project unit daily for 6 weeks, and nurses on the project unit and a comparison unit completed the SOPS 1.0 before and after the intervention. Monthly error reporting was tracked on those same units. RESULTS Error reporting by nurses significantly increased during and after the intervention on the project unit ( P = .012) but not on the comparison unit. SOPS 1.0 items purported to measure reporting culture showed no significant differences after the intervention or between project and comparison units. Only 1 composite score increased after the intervention: communication openness improved on the project unit but not on the comparison unit. CONCLUSION Using a Safety Huddle Intervention to promote conversation about error events has potential to increase reporting of errors and foster a sense of communication openness. Both achievements have the capacity to improve patient safety.
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Affiliation(s)
- Margaret Malague MacKay
- School of Nursing, The University of North Carolina at Charlotte (Drs Jordan and Powers); Levine Children's Hospital at Atrium Health in the Nursing Department, Charlotte, North Carolina (Dr MacKay); and Department of Interprofessional Research, Atrium Health, Charlotte, North Carolina (Dr Munn)
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Gleeson L, McNamara J, Donworth E, Crowley E, Delaney A, Sahm L, O'Mahony D, Russell N, Byrne S. Healthcare provider perceptions of safety culture: A multi-site study using the safety attitudes questionnaire. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 9:100228. [PMID: 36793798 PMCID: PMC9922969 DOI: 10.1016/j.rcsop.2023.100228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
Introduction Patient safety culture, the way in which members of a healthcare organisation think about and prioritise safety, has been linked to positive patient outcomes. The aim of this study was to use the Safety Attitudes Questionnaire (SAQ) to measure the safety culture in a variety of healthcare settings located in the province of Munster of Ireland. Methods The SAQ was applied in six healthcare settings in the Munster province of Ireland between December 2017 and November 2019. The attitudes of healthcare staff towards six domains of safety culture were assessed over 32 Likert-scaled items. The mean, median, interquartile range and percent positive scores for each domain were calculated for the study population, and subgroup analyses were carried out between study sites and professions. Results for each setting were compared to international benchmarking data. Chi-Squared tests were used to determine whether study site or profession were related to domain scores. Reliability analysis was carried out using Cronbach's alpha. Results Study participants (n = 1749) comprising doctors, pharmacists, nurses, and healthcare assistants, were found to have positive attitudes towards patient safety culture but scored poorly in the domains Working Conditions and Perceptions of Management. Perceptions of safety culture were more positive in smaller healthcare settings, and amongst nurses and HCAs. The survey had acceptable internal consistency. Conclusions In this study investigating the safety culture of healthcare organisations in Ireland, study participants had generally positive attitudes towards the safety culture in their organisation, however working conditions, perceptions of management, and medication incident reporting were identified as key areas for improvement.
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Affiliation(s)
- L.L. Gleeson
- School of Pharmacy, University College Cork, Ireland
| | - J. McNamara
- School of Pharmacy, University College Cork, Ireland
| | - E. Donworth
- School of Pharmacy, University College Cork, Ireland
| | - E.K. Crowley
- School of Pharmacy, University College Cork, Ireland
| | | | - L. Sahm
- School of Pharmacy, University College Cork, Ireland
| | | | | | - S. Byrne
- School of Pharmacy, University College Cork, Ireland
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Fernandez R, tenHam-Baloyi W, Mathew E, Secginli S, Bahar Z, Jans C, Nahcivan N, Torun G, Lapkin S, Green H. Predicting behavioural intentions towards medication safety among student and new graduate nurses across four countries. J Clin Nurs 2023; 32:789-798. [PMID: 35475307 PMCID: PMC10083919 DOI: 10.1111/jocn.16330] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/29/2022] [Accepted: 04/01/2022] [Indexed: 01/17/2023]
Abstract
AIMS AND OBJECTIVES To identify final-year undergraduate students and new graduate nurses' behavioural intentions towards medication safety across four countries. BACKGROUND Medication errors are a common and avoidable occurrence, being costly for not only patients but also for health systems and society. DESIGN A multi-site cross-sectional study. METHODS A self-administered survey was distributed to students and new graduate nurses in South Africa, India, Turkey and Australia. Descriptive statistics were calculated for all survey items. Multiple linear regressions were performed to predict behavioural intentions using the three Theory of Planned Behaviour constructs: attitudes, behavioural control and subjective norms. This study adheres to the STROBE guidelines. RESULTS Data were analysed for 432 students and 576 new graduate nurses. Across all countries, new graduate nurses reported significantly higher scores on all the TPB variables compared with student nurses. Attitudes towards medication management were found significantly and positively related to intention to practice safe medication management for both student and new graduate nurses. Total perceived behavioural control was significantly and negatively related to intention to practice safe medication management for students. CONCLUSION Student and new graduate nurses showed favourable attitude, subjective norm, perceived behaviour control and intention in practising medication safety. However, differences in countries require further exploration on the factors influencing attitudes towards medication safety among student nurses and new nurse graduates. RELEVANCE TO CLINICAL PRACTICE Understanding student and new graduate nurses' medication administration practices is important to inform strategies aimed at improving patient safety. The findings of this study highlight the need for an internationally coordinated approach to ensure safe medication administration by student and new graduate nurses.
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Affiliation(s)
- Ritin Fernandez
- Centre for Research in Nursing and Health, St. George Hospital, Kogarah, New South Wales, Australia.,Centre for Evidence Based Initiatives in Health Care: A Joanna Briggs Centre of Excellence, Wollongong, New South Wales, Australia.,School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Wilma tenHam-Baloyi
- Faculty of Health Sciences, Nelson Mandela University, Gqeberha, South Africa
| | - Elsheba Mathew
- Community Medicine, Pushpagiri Medical College Hospital, Thiruvalla, India.,Pushpagiri Centre for Evidence Based Practice (PCEBP) - A JBI Affiliated Group, Tiruvalla, India
| | - Selda Secginli
- Florence Nightingale Nursing Faculty, Public Health Nursing Department, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Zuhal Bahar
- Department of Nursing, Faculty of Health Sciences, Istanbul Aydin University, Istanbul, Turkey
| | - Carley Jans
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Nursen Nahcivan
- Florence Nightingale Nursing Faculty, Public Health Nursing Department, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Gizemnur Torun
- Department of Public Health Nursing, Kocaeli University, Kocaeli, Turkey
| | - Samuel Lapkin
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Heidi Green
- Centre for Research in Nursing and Health, St. George Hospital, Kogarah, New South Wales, Australia.,Centre for Evidence Based Initiatives in Health Care: A Joanna Briggs Centre of Excellence, Wollongong, New South Wales, Australia
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Afaya A, Konlan KD, Kim Do H. Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review. BMC Health Serv Res 2021; 21:1156. [PMID: 34696788 PMCID: PMC8547021 DOI: 10.1186/s12913-021-07187-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 10/18/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of the third WHO challenge released in 2017 was to attain a global commitment to lessen the severity and to prevent medication-related harm by 50% within the next five years. To achieve this goal, comprehensive identification of barriers to reporting medication errors is imperative. OBJECTIVE This review systematically identified and examined the barriers hindering nurses from reporting medication administration errors in the hospital setting. DESIGN An integrative review. REVIEW METHODS PubMed, Web of Science, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) including Google scholar were searched to identify published studies on barriers to medication administration error reporting from January 2016 to December 2020. Two reviewers (AA, and KDK) independently assessed the quality of all the included studies using the Mixed Methods Appraisal Tool (MMAT) version 2018. RESULTS Of the 10, 929 articles retrieved, 14 studies were included in this study. The main themes and subthemes identified as barriers to reporting medication administration errors after the integration of results from qualitative and quantitative studies were: organisational barriers (inadequate reporting systems, management behaviour, and unclear definition of medication error), and professional and individual barriers (fear of management/colleagues/lawsuit, individual reasons, and inadequate knowledge of errors). CONCLUSION Providing an enabling environment void of punitive measures and blame culture is imperious for nurses to report medication administration errors. Policymakers, managers, and nurses should agree on a uniform definition of what constitutes medication error to enhance nurses' ability to report medication administration errors.
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Affiliation(s)
- Agani Afaya
- College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea. .,School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana.
| | - Kennedy Diema Konlan
- College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.,School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
| | - Hyunok Kim Do
- College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
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