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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Event
    Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations. Being open and apologising when things go wrong. Challenges/complexities associated with cases where there is more than one investigation. Effective communication, including dealing with conflict and difficult conversations. Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation. Sharing findings. Signposting and support: including loss, trauma and stress. WHO SHOULD ATTEND Lead investigators conducting patient safety incident investigations. Executive and service lead for duty of candour. Executive and service lead for patient safety. Executive and service lead for the supporting response to patient safety incidents. Investigators supporting patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  2. Event
    This course will explain and discuss the statutory duty of candour in principle, in practice, and in context, using real examples of good and poor practice. Openness, trust and good communication are at the core of the relationship between health and care professionals and their patients / families. But the duty of candour is widely misunderstood, and often misapplied, which can leave practitioners feeling exposed and patients / families feeling frustrated and, perhaps, push them towards other legal processes to get answers. This course will help attendees to understand the relationship between the statutory and professional duties of candour, in the wider context of the importance of good communication and the reasons why complaints and claims are made. We will look at each element of the legal test for a notifiable safety incident to trigger the duty of candour, and the next steps that are necessary, reflecting in particular on the importance of distinguishing fault and blame as irrelevant to the duty of candour. Examples will be given of regulatory consequences where the duty of candour has not been implemented appropriately and we will discuss the part of the duty of candour that requires an apology to be given, and consider the legal implications of this as well as good practice and examples to avoid where a poor apology has made things worse. WHO SHOULD ATTEND Health and social care professionals, front line practitioners and managers, including those dealing with complaints and claims. KEY LEARNING OBJECTIVES Understanding the importance of communication in a clinical context and the role of the duties of candour. Appreciating the difference between the statutory and professional duties of candour. The key elements of the statutory duty of candour for a notifiable safety incident, and the overarching duty to be open and transparent. Understanding the process when the duty of candour is triggered. Understanding the relationship between the duty of candour and fault / blame / liability. The legal implications of an apology and what makes a good apology. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  3. Event
    An all-day immersive learning experience dedicated to enhancing your understanding and practical skills in conducting Mock CQC Inspections. Designed for healthcare professionals, inspectors, and facility managers, this masterclass is your ticket to understanding and navigating the complexities of the CQC inspection process. Navigating the intricate realm of CQC inspections is a vital skill in maintaining and elevating the standards of healthcare. Our all-day masterclass is meticulously crafted to equip participants with both the theoretical knowledge and practical skills needed to conduct insightful and effective Mock CQC Inspections. Invest a day in our masterclass and take a significant step towards excellence in healthcare regulation and quality improvement. It’s more than learning; it’s about crafting excellence in the care you deliver. Who should attend? This masterclass is ideal for healthcare professionals, inspectors, facility managers, and anyone involved in the regulation, management, and continuous improvement of healthcare services. Key learning objectives: The Importance of Inspections: Understand why CQC inspections are vital in ensuring quality and compliance within healthcare settings. The Inspection Process: Gain a comprehensive insight into how CQC inspections are planned, conducted, and followed up. Five Key Questions: Delve into the critical areas of safety, effectiveness, care, responsiveness, and leadership. Types of Inspections: Learn the distinctions between comprehensive and targeted inspections and how to apply them in different scenarios. Identifying & Rectifying Issues: Acquire the skill to detect potential problems and implement corrective actions efficiently. Post-Inspection Protocols: Understand the art of crafting detailed inspection reports and how to set forth clear and actionable improvement recommendations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  4. Event
    This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives: Understanding the role of the Senior Information Risk Owner Identifying Information Risks across the organisation Working with others to mitigate the risk to patients, staff and organization. Confidence that all reasonable technical and organisation measure are in place Giving assurance to the Board that risks have been considered, mitigated or owned Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  5. Event
    This one day masterclass, facilitated by Glenys Hurt-Robson, Associate Facilitator, The Athena Programme will support you to develop your role and responsibility as a Designated Safeguarding Officer / Designated Safeguarding Lead / Named Professional for safeguarding in your organisation. It will enable you to understand one or both of the Child and Adult abuse investigation processes under Working Together to Safeguard Children (2018) and / or the Care Act 2014. This course will connect emotionally with your safeguarding core. It will stimulate and support you as you reflect on the key responsibilities of the role and how these relate to your organisational context. Against a backdrop of current safeguarding legislation (Children Act 2004, Care Act 2014) it will help you examine your own role and the roles of others in the multi-agency world of protecting and supporting children and adults at risk. The skills and knowledge gained will raise your awareness of current risks and allow you to proactively develop your safeguarding role. The course will assist in building your resilience in dealing with allegations against staff and in-depth understanding of how to protect and support those involved. The content is based on current NHS Intercollegiate Documents - Roles and Competencies for Safeguarding and pitched at NHS level 4 for named professionals. Key learning objectives: To understand the purpose, importance and role of the Designated Safeguarding Officer / Lead for safeguarding children and adults at risk. Explore the emotional impact from the disclosure of abuse. Explore the roles and responsibilities of other Safeguarding partners. Understand how to respond to those who are the subject of concerns or allegations of abuse and identify ways in which the Designated Safeguarding Officer can support staff and work with partners e.g.HR, LADO, DBS. How to manage and support staff through the process of allegations and/or disclosures/whistleblowing. Understand and explore in-depth your organisations safeguarding policies and procedures. Understand how your own values and beliefs can affect your role and responsibilities as a DSO exploring the emotional dimensions of safeguarding work for you and your workforce. Identify and understand the barriers to reporting and effective information sharing. To explore the difficult decisions to be made and the people they need to be made with. Understand how other Safeguarding Arrangements impact on Safeguarding, i.e. MARAC, MAPPA, Prevent Duty, FGM Duty, contextual safeguarding etc. To act as a source of support, advice and expertise within the organisation and liaising with relevant agencies and reviews e.g. SCR’s and SAR’s. Action planning section for development of Designated Safeguarding Officer teams. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  6. News Article
    The NHS and government have failed to implement a single recommendation from a key Jimmy Savile inquiry – almost 10 years after plans to prevent future sex abuse of patients in hospitals were put forward, The Independent can reveal. The shocking discovery was uncovered by the panel tasked to chair the public inquiry into Lucy Letby, the nurse who killed several newborn babies in her care. Analysing the progress made by the NHS and government after some of the most high-profile health scandals in the UK, it found across 30 inquiries, dating back to 1967, just 302 out of more than 1,400 key recommendations had been adopted. Alan Collins, a lawyer who represented dozens of victims in claims against Savile’s estate, slammed politicians and public bodies over the failure. He says: “The thread that runs through the numerous reports, the investigations behind them, and the ongoing failures with lack of implementation is the lack of accountability. “We have seen time after time the lack of professional curiosity in the face of glaring wrongdoing yet this cultural vacuum rarely sees those charged with responsibility for safeguarding subject to any consequences.” Read full story Source: The Independent, 3 June 2024
  7. News Article
    Patients are being squeezed onto wards, forced to have intimate examinations in front of each other and left dying in hospital corridors as nurses are forced to play “trolley tetris”, NHS staff have revealed. Testimonies from nurses, given to the Royal College of Nursing and seen by The Independent, reveal they are regularly forced into “unsafe” practices, such as squeezing more patients into wards with insufficient space and staffing. The warnings come as the RCN has urged the next government to act on the “national emergency” with a survey of thousands of nurses revealing patients are being left without access to oxygen and put in undignified situations. RCN deputy chief nurse Lynn Woolsey said in May: “We have increasing evidence from members up and down the country of patients being cared for in undesignated bed spaces, vending machines being moved out of A&E to make space for patients, two patients being put in one bed space, with one patient being asked to face the wall while a rectal exam was carried out on the other patient... shocking, shocking information and situations.” In the face of the worsening A&E and ambulance waiting times last year, The Independent revealed hospital staff in many areas were ordered to move patients from emergency departments on, regardless of space. In one example, a nurse said her trust ordered workers to accept patients from A&E at midday every day, adding: “Doesn’t matter what capacity A&E is or the ward. It’s just what has to be done. We have no space, no tables, no curtains.” Read full story Source: The Independent, 3 June 2024
  8. News Article
    The families of nine babies who died at a scandal-hit NHS trust over a three-year period have called for a public inquiry into the standard of its maternity care. A collective letter has been sent to each of the families' MPs after they lost babies at hospitals run by the University Hospitals Sussex NHS Foundation Trust. Of the nine bereaved mothers, four said they too almost died as a result of "poor standards of care" from maternity teams between 2021 and 2023 The trust said it had recruited more midwives and "changed" how it supported families, with outcomes now better "than most other trusts in the country". But the Sussex-based families said they had called for a public inquiry into its maternity services to ensure accountability for "systemic failures", and so the trust learns from past mistakes. In the letter to the MPs, the parents said: "With the volume and repetition of errors in maternity care by the trust, we believe that babies and potentially mothers will continue to unnecessarily die under the trust’s care unless there is additional intervention." Read full story Source: BBC News, 4 June 2024
  9. Content Article Comment
    @Compliance Manager Thanks for highlighting. The link to the page has now been added.
  10. Event
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    Organisational environments are complex systems of people, laws and policies, shaped and sustained by culture. This year’s conference will highlight aspects of positive cultures that support the reduction of restrictive practices. Sharing evidence-based information and tools, the event will promote effective practice, open discussion, and dialogue. Hear from policy and practice leaders, people with lived experience and academics who will stimulate discussion over two days in Newcastle. Implementation of any initiative to reduce restrictive practices is determined by shared ways of thinking, feeling, and behaving. By exploring latest thinking on all forms of restrictive practice within the context of your organisation, you can learn practical ways to navigate systemic barriers that impact people’s lives and can result in institutional forms of oppression. The Restraint Reduction Network conference promotes trauma informed and experience-sensitive ways of supporting distress and recovery. The conference will be of interest to those working in health, social care, education and secure services, including policy and implementation leads. Register
  11. Event
    The Virtual Wards Conference aims to bring together senior healthcare professionals, policy leaders, and industry stakeholders to examine and tackle key challenges in the sector. By fostering collaboration and sharing knowledge among NHS peers, the conference aims to improve the virtual wards sector, leading to enhanced patient care. This event serves as a timely platform to promote innovation and collaboration, crucial for the effective management of virtual wards within the NHS and the overall improvement of the healthcare industry. Key content streams: Virtual Ward Planning and Implementation: creating understanding, confidence and credibility among patients and clinicians during the process of creating a virtual ward service for patients. The Future of Virtual Wards: the use of digital innovations to reduce pressures on the health and care system. Challenges and Opportunities of Virtual Wards: looking at the solutions to improve virtual wards, increasing their efficiency and ability to provide an effective pathway for both clinicians and patients and overcome any new and existing challenges. Workforce Narrative: implications of the workforce, how the NHS workforce long-term plan will play a role to better the virtual ward service. Register
  12. Event
    Delivering high-quality care and ensuring the best patient outcomes and safety levels should be the goal of all health care providers; however, these can only be achieved if staff are able and encouraged to work to the best of their abilities. Leaders play a crucial role in creating a culture that drives good staff and patient experience and, in turn, quality across the system. In this context, this session from the King's Fund will: help to provide understanding about the relationship between working culture and high-quality patient care explore how leaders can create a safe and supportive work culture that drives quality   discuss how a culture of quality can improve staff wellbeing and resilience provide insight into how successful quality-improvement strategies place a strong focus on staff engagement and staff experience. Register
  13. Content Article
    The National Academies of Sciences, Engineering, and Medicine (NASEM) report Improving Diagnosis in Health Care calls for healthcare professionals to engage patients in diagnostic decision making. Patient engagement refers to the concept of patients being actively involved in their healthcare, including but not limited to engaging with medical providers and the health system in diagnosis, treatment, and overall disease management decisions.  The emergency department (ED) presents unique challenges to engage patients in the diagnostic process. Patients evaluated in the ED typically have no prior relationship with the care team. Engagement is further challenged in the unpredictable, chaotic environment where clinicians operate in time-constrained situations and care for multiple patients simultaneously. Finally, patients presenting to the ED may be critically ill, emotionally distressed, intoxicated, or otherwise unable to fully participate in their own care. Health information technology (IT) is increasingly used to promote patient engagement by enhancing patient-provider communication, ensuring shared decision making, and enabling positive behavioural changes. Health IT tools such as electronic patient portals, mobile text messaging, health apps, and recent advancements in virtual environments offer new opportunities for patient engagement in the ED. This Agency for Healthcare Research and Quality (AHRQ) brief reviews the current state of health IT-based methods for engaging patients in the diagnostic process in the ED and outlines opportunities for further development.
  14. News Article
    A new artificial intelligence tool (AI) developed in the UK can rapidly rule out heart attacks in people attending A&E and help tens of thousands avoid unnecessary hospital stays each year, according to its creators. Known as Rapid-RO, the AI tool has been found to successfully rule out heart attacks in over a third of patients across four UK hospitals during trials. Professor James Leiper, associate medical director at the British Heart Foundation (BHF), which funded the study, said: “This research demonstrates the important role AI could play in guiding treatment decision for heart patients. “By quickly identifying patients who are safe to be discharged, this technology could help people avoid unnecessary hospital stays, allowing valuable NHS time and resource to be redirected to where it could have the greatest benefit.” Read full story Source: The Independent, 3 June 2024
  15. News Article
    Overcrowding is forcing hospitals to treat so many patients in corridors and storerooms that it constitutes a “national emergency”, the UK’s nursing union has said. The growing and widespread practice is endangering patients’ safety by leaving them without oxygen or easily able to attract staff’s attention, the Royal College of Nursing (RCN) warned. “Corridor care” also deprives patients of their dignity because they have to undergo intimate examinations in view of others and do not have easy access to a toilet, it added. Hospitals become so stretched that some patients have died while being looked after in what the RCN said were “inappropriate areas”, which can also include car parks and fracture rooms. The RCN called on the NHS to recognise the serious risk “corridor care” posed to patients by recording every time it happened and classifying it as a “never event”. The latter would put it on a par with incidents such as surgeons operating on the wrong part of someone’s body. A new RCN report, based on a survey of 11,000 nurses across the UK, includes evidence of the impact on patients and staff of care being delivered in such settings. One nurse said: “You wouldn’t treat a dog this way.” Nurses described patients being told they had cancer while they were in public areas, and someone with dementia being left for hours without oxygen in a corridor. Read full story Source: The Guardian, 3 June 2024 Related reading on the hub: A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
  16. Content Article
    In a new Royal College of Nursing report, survey findings and member testimonies show the full grave picture of corridor care across the UK. Of those forced to deliver care in inappropriate settings, over half (53%) say it left them without access to life-saving equipment including oxygen and suction. More than two-thirds (67%) said the care they delivered in public compromised patient privacy and dignity. Thousands of nursing staff report how corridor care has become the norm in almost every corner of a typical hospital setting. Heavy patient flow and lack of capacity sees nursing staff left with no space to place patients. What would have been an emergency measure is now routine. The report says corridor care is “a symptom of a system in crisis”, with patient demand in all settings, from primary to community and social care, outstripping workforce supply. The result is patients left unable to access care near their homes and instead being forced to turn to hospitals. Poor population health and a lack of investment in prevention is exacerbating the problem, the report says. The RCN are asking for mandatory national reporting of patients being cared for in corridors, to reveal the extent of hospital overcrowding, as part of a plan to eradicate the practice. They also need members to raise concerns when care in inappropriate settings takes place.  Related reading on the hub: A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
  17. News Article
    Young women from West Yorkshire have criticised a "lack of support" available for a painful and debilitating medical condition. The three patients, all in their 20s, said they either struggled to get a diagnosis of polycystic ovary syndrome (PCOS) confirmed despite numerous GP appointments, or were not given effective treatment. PCOS causes painful and irregular periods, and affects up to one in 10 women in the UK. The NHS said it "strongly advised" any woman concerned about their health to contact their GP. Alex Offer, 24, from Leeds, said it took nine years before she was told she had PCOS after doctors "ignored" her concerns from the age of 15. One GP dismissed her symptoms as being caused by stress and anxiety, she said. Laaraib Khan, 24, also from Leeds, reported a similar experience. Although she received her diagnosis at the age of 13 after her mother pushed her GP to take her complaints seriously, in the past 11 years she said she had been given "little support" and was left to manage the syndrome herself. "You have to lean on other women who are going through it rather than going to your GP, who will most likely turn you away," she said. Research by the charity Verity PCOS UK found that 60% of women with the disorder have struggled to get a diagnosis, while 95% said they had encountered problems trying to access NHS support. Read full story Source: BBC News, 3 June 2024
  18. Content Article
    This book introduces quality improvement for anyone studying or working in healthcare. Written in clear, straightforward language, it explores quality improvement from multiple perspectives and outlines a range models and toolkits you can use in practice. Encouraging you to reflect on your role as an improver, the book equips you with the knowledge and skills you need to work through each stage of the improvement process – from troubleshooting an issue, to working with others to make an improvement, through to its evaluation. Key features: Case studies and activities help you to apply theory and methodology to your everyday role.  A comprehensive glossary introduces quality improvement terminology and concepts. A logical four-part structure moves from the basics up, building your knowledge and understanding as you go.
  19. Content Article
    The UK Council on Deafness created Deaf Awareness Week (6-12 May) to increase the visibility of challenges the deaf community face and educate others on how they can support them. Patient Safety Learning has pulled together seven useful resources shared on the hub to help healthcare professionals, friends and family communicate and support people with hearing loss or deafness.
  20. Content Article
    Healthcare services improvisation relies heavily on collaborating with patients and caregivers by acknowledging their feedback to enhance quality and safety. The 2023 World Patient Safety Day underscores the significance of co-production with patients in safety strategies. In accordance with this, a crucial tool that involves patients and caregivers is the “Patient-reported experience measures (PREMs)” that help in assessing healthcare delivery in terms of quality, safety and performance. These tools for various healthcare processes offer valuable insights into treatment effectiveness and areas needing improvement. PREMs are surveys used to assess patients' care experiences objectively, aiding in pinpointing the areas for improvement. Unlike patient satisfaction measures, which reflect only subjective evaluations, PREMs offer an objective view of care encounters. In view of the importance of a standardised tool for Indian health care organisations, CAHO in collaboration with various stakeholders and patients unveil the White paper on Patient-Reported Experience Measures (PREMs) tool development process. This white paper was released by the honourable governor of West Bengal, Dr C.V Ananda Bose at the recently concluded CAHOCON 2024 at Biswa Bangla, Kolkata.
  21. News Article
    Women have been told to avoid using weight-loss drugs to help them get pregnant, as doctors report a rise in surprise “Ozempic babies”. Some women struggling with infertility have unexpectedly become pregnant after being prescribed semaglutide, which is used to treat obesity and type 2 diabetes under the brand names Wegovy and Ozempic. However, scientists have now issued a warning that the weight-loss injections may cause birth defects and should not be used by anyone hoping to become pregnant. Professor Tricia Tan, from the department of metabolism, digestion and reproduction at Imperial College London, said: “Women need to know that these drugs should not be used during pregnancy. You can also see that most of the clinical trials have not included women who are intending to become pregnant. Animal studies did show that the animal babies born to animals who were given these medications had problems.” Read full story (paywalled) Source: The Times, 23 April 2024
  22. Event
    WHO/Europe, the Austrian National Public Health Institute—a WHO-Collaborating Center for Health Promotion in Hospitals and Healthcare— EACH: International Association for Communication in Healthcare, and the University of Iowa have joined forces to deliver a unique series of webinars that will examine the critical role of effective communication in building trust within healthcare settings and the challenges healthcare professionals face in effectively communicating with each other and patients. This series also aims to inform future WHO guidance and recommendations on establishing national communication skills training programs in hospitals, drawing on insights and lessons from such programs in various countries. The first webinar provides a comprehensive overview of WHO/Europe's focus on trust and the foundational role of effective communication in hospitals. Experts will delve into the importance of patient-centred communication and how this approach improves patient outcomes, strengthens the patient-healthcare provider relationship, and builds trust. Experts will also discuss the role of transparent and empathetic communication in fostering trust when navigating adverse situations. Participants will hear about the advantages of establishing large-scale structured communication training programs and a case study illustrating the successful implementation of a mandatory Provider Communication Program across a hospital system, demonstrating practical applications of effective communication strategies. Speakers: Natasha Azzopardi Muscat, Director the Division of Country Health Policies and Systems at the WHO Regional Office for Europe Marlene Sator, a Senior Health Expert at the Austrian Public Health Institute and WHO Collaborating Centre for Health Promotion in Hospitals and Healthcare Joao Breda, Head of the WHO Office for Quality of Care and Patient Safety in Athens Marcy Rosenbaum, Professor of Family Medicine at the University of Iowa, past-president of EACH, and former Co-chair of EACH Theresa Brennan, Chief Medical Officer at the University of Iowa Hospitals and Clinics and Professor of Internal Medicine Register
  23. Content Article
    At a recent meeting of the 'Safer Healthcare Biosafety Network' (SHBN), members learned of a new initiative designed to improve the safety of healthcare workers in the event of a future pandemic. It should also greatly reduce nosocomial (healthcare acquired) infection. David Osborn explained that the intention is to shift the focus for respiratory protective equipment (RPE) away from FFP3 respirators more towards powered air-purifying respirators (PAPRs). Although FFP3s provide efficient protection, they have several disadvantages for use in the healthcare sector, particularly when providing prolonged care of infectious patients. At the height of the pandemic, given the shortage of respirators, a new type of PAPR was developed at Southampton University and used to great effect. Staff reported that, whilst previously they had been coming to work in fear of infection, they now felt safe and secure in the knowledge that they were well protected. David is supporting Professor Kevin Bampton (Chief Executive, British Occupational Hygiene Society) and Professor Paul Elkington (Director, Institute for Medical Innovation, Southampton University). Following the SHBN, David prepared a briefing note (attached below) providing more details of the project.
  24. News Article
    Urgent government action is needed to stop preventable asthma deaths, a leading charity has said. More than 12,000 people in the UK have died from asthma attacks since 2014, according to Asthma and Lung UK. It said the figures meant "shockingly little" had changed since a major report a decade ago which found two thirds of asthma deaths could have been avoided with better care. People with asthma should get an annual condition review, a written action plan and inhaler technique checks. But the charity said people with asthma were being "failed", with seven out of 10 not receiving basic care, partly because healthcare workers were over-stretched. Asthma and Lung UK said 31% of asthmatics were "disengaged" with managing their condition, putting them at higher risk, according to its research. Ministers in England and Wales said they were trying to improve services. Read full story Source: BBC News, 24 April 2024
  25. News Article
    Patients needing urgent treatment for life-threatening illness such as strokes or heart attacks waited more than 24 hours for an ambulance response, new figures show. New data shows the crisis facing NHS ambulance services resulted in every region missing vital NHS targets to respond to some of the most critically unwell patients last year. Despite improvements compared to 2022, figures obtained by the Liberal Democrat party show ambulance services continued to struggle with response times to category two patients, which may include those who have suffered a stroke or heart attack and should receive a response within 18 minutes. In two cases patients needing this level of response, in Warrington and Staffordshire, waited more than 25 hours for an ambulance. Sir Julian Hartley, chief executive at NHS Providers, which represents all NHS trusts, called for “urgent” investment and warned that “rising demand, limited resources and vast staff shortages are piling pressure on an already-stretched service, further driving up ambulance waiting times.” He said NHS hospital and ambulance leaders are working to reduce delays and responses at a time “when demand has never been higher.” Read full story Source: The Independent, 23 April 2024
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