Report: Hospital Medication Errors Commonplace From mix-ups caused by similar-sounding names to accidental overdoses, more than 1.5 million people in hospitals and nursing homes are injured each year by medication errors, according to a new report from the Institute of Medicine.
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Report: Hospital Medication Errors Commonplace

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Report: Hospital Medication Errors Commonplace

Report: Hospital Medication Errors Commonplace

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JOE PALCA, host:

This is TALK OF THE NATION: SCIENCE FRIDAY from NPR News. I'm Joe Palca. Ira Flatow is away.

If you're a patient in a hospital, you can expect on average to be subjected to at least one medication error each day. That's the alarming conclusion of a new report from the Institute of Medicine.

Nursing home residents don't fair any better. According to one estimate, at least 800,000 drug-related injuries occur in long-term facilities each year.

Combined with the mistakes made in outpatient clinics and doctors' offices, the Institute of Medicine Committee estimates that at least 1.5 million people suffer from a medication error each year. So what's going on, and how can the situation be improved?

That's what we'll be talking about for the rest of the hour. If you'd like to get in on the conversation, give us a call. Our number is 800-989-8255. That's 1-800-989-TALK. And if you want more information about what we'll be talking about this hour, go our Web site,, where you'll find links to our topic.

Now let me introduce my guests. David Bates was a member of the Institute of Medicine Committee that looked at medication errors. He is the chief of the Division of General Medicine at Brigham and Women's Hospital. He joins us today by phone. Thanks for talking with us, Dr. Bates.

Dr. DAVID BATES (Member, Institute of Medicine Committee on Identifying and Preventing Medication Errors): Thank you for having me.

PALCA: And then also we have Donald Berwick. He is president and CEO of the Institute for Healthcare Improvement. He's also a clinical professor of pediatrics and health care policy at Harvard Medical School and a professor of health policy and management at the Harvard School of Public Health. He joins us by phone from South Africa. Wow, thanks for joining us today, Dr. Berwick.

Dr. DONALD BERWICK (President and CEO, Institute for Healthcare Improvement; Professor of Pediatrics and Health Care Policy, Harvard Medical School): My pleasure, Joe. Thank you.

PALCA: So let's start with you, Dr. Bates. These numbers are pretty staggering. Should patients be terrified when they enter the hospital?

Dr. BATES: No, I don't think they should be terrified, but I do think that it's important to be aware that there is a risk and to recognize that there are some things that they can do to make things safer.

PALCA: Such as?

Dr. BATES: Well, one example would be to ask the doctor or nurse what drugs they're being given, not to take a drug without being told why, exercise their right to have someone else, a surrogate, present when they're getting medications, and when they can't, keep track of what's going on themselves. And then before discharge, asking for a list of medications that they should be taking at home and having someone go over them with them.

PALCA: So, okay, that sounds like a very rational set of guidelines and good advice. But having been a hospital patient once myself and been with family members who are in the hospital, nobody's thinking clearly enough to do all that when they're facing a hospitalization. How is anybody going to maintain that list?

Dr. BATES: Well, I think that's fair, and certainly there are many times when a person is in pain or is not able mentally to necessarily go through all that, and I think hospitals have a lot of responsibilities, too, to make sure that the - that things happen right. The report also identified a number of things that hospitals can do to improve the safety of delivery of medications.

PALCA: I see. Okay, well, some years ago, there was - I guess in 1999, there was another report by the Institute of Medicine called To Err is Human, and at that time, there was an alarming number, that there were hundreds of thousands of people who were dying each year as a result of medication errors. And Dr. Berwick, I understand you've started a project called The 100,000 Lives Campaign. What's that about, and how is it going?

Dr. BERWICK: Well, we're building on the lessons of that Institute of Medicine report which showed injuries to patients not just from medication errors -they're about 25 percent of the injuries - but from other causes of error really hurt people in healthcare too frequently.

We started a campaign 18 months ago to try to save 100,000 lives in American hospitals by encouraging hospitals to make basically six changes in the way they take care of patients and thereby make care far safer.

PALCA: So, okay, so your project is aimed at hospitals. You heard Dr. Bates tell us that patients should take more responsibility. How does that fit into your plans?

Dr. BERWICK: Well, patients can certainly help. One of the key maneuvers in our 100,000 Lives Campaign is medication reconciliation processes. Errors are introduced in medication management when patients cross boundaries within the hospital or from the hospital to home or nursing homes. If they do what Dr. Bates just said, which is maintain medication lists, know what they're on, understand why they're on things, they can actually help reduce some of those errors.

PALCA: Is it part of the culture of hospitals to share that information, because it's always been a little bit obscure. You know, they give you something, you take it, and if you ask, you're being a pest.

Dr. BERWICK: Well, I'm glad you mentioned culture. It is a culture change. It's not just technical. We need to change the way we - our beliefs in healthcare. Patients could be far more active participants in their own care, and that's not shifting the buck, that's giving them power. It's going to change the way we talk to patients. In fact, the Institute of Medicine talks a lot about the way doctors and nurses talk to patients and listen to them to help them understand what's happening to them.

PALCA: But I want to go back to this question of patient information, Dr. Bates. A patient can be informed about what he or she is taking, but they're not going to know about drugs that don't interact properly, they're not going to know about doses, they're not going to know about allergic reactions necessarily unless they've had one, or even know how to recognize one if they're having one. So how - I mean, how is this going to work?

Dr. BATES: Now, that's exactly right. So one of the big changes that can most improve medication safety is to have providers write the prescriptions on the computer, and the - basically, even physicians can't keep track of all the drugs that interact or all the allergies that a patient might have.

If prescriptions are written on the computer they can be checked for interactions, drugs that shouldn't be given together, check for allergies, the right dose can be suggested. And work that we and others have done demonstrates that that results in much higher level of medication safety.

PALCA: There's a modern aphorism, though, that goes something like to err is human, but to really mess up you need a computer.

(Soundbite of laughter)

PALCA: How confident are you that getting computers to be the sort of the final arbiter is going to improve things and not make it worse?

Dr. BATES: Computers can certainly introduce errors as well as prevent then. But studies that we've done that look at both the errors that are introduced and the errors that are prevented show that you can reduce the medication error rate more than 80 percent by computerizing the process. That being said, when hospitals make a change and introduce some new system like computerized prescribing they need to check to make sure that new errors are not being introduced.

PALCA: Okay. Well, let's see what some of our listeners have to say at this point about this kind of an issue, because, unfortunately, as I read some of these documents, four out of five Americans are taking some sort of a medication, whether it's an over-the-counter or prescription or even a food supplement, almost everyday. And so it's obviously something people should be aware of.

But let's first go to Cathy(ph) in Honolulu, Hawaii. Cathy, welcome to the program.

CATHY (Caller): Hi. Thank you so much for having this on your show. I cannot tell you how important this is. I have firsthand experience because my mother is in a nursing facility and she is terminal. I stayed with her in the facility for almost six weeks, living in the room with her, and this is a very high-end, expensive facility, and I was absolutely appalled at the constant errors in medication.

PALCA: What sort of errors? Were they errors of giving the wrong medicine or giving too much or not giving - or giving something by accident?

CATHY: It was actually - it started out the reason I went up there was when my mother went into narcotics withdrawal because they had failed to order her prescription pain patch, and she had to be rushed to the hospital because they couldn't find a doctor to issue the pain patch for her.

PALCA: Mm-hmm.

CATHY: And I went up there, and I found that she was on all sorts of medication she did not need. She was on medication that made her sick - over-the-counter stuff like calcium pills; they were giving her these huge calcium pills on an empty stomach and then wondered why she got nauseated.

PALCA: Mm-hmm.

CATHY: Would give her anti-nausea pills, which made her even worse, and then she would throw up, and it was just - it was an endless cycle of almost lunacy. I was just devastated.

PALCA: Okay, Cathy, let's see what our experts have to say about that. Dr. Berwick, maybe I could start with you. I mean, do your six points - I know you were dealing with hospitals, not nursing homes, but do your six points cover the kinds of issues that Cathy's raising?

Dr. BERWICK: Well, they certainly address some of the frailty of the healthcare system. Cathy, unfortunately, like a lot of patients and loved ones, are observing how frail these systems are. We're still operating 19th century healthcare systems.

An important part of Cathy's story, though, that's positive is that she was there, although it must have been heroic for her to be there for six weeks with her mother. Taking someone with you to act as an assistant and to watch the care and help defend the patients is not a bad move right now, given the way the systems are until we implement some of the recommendations that the Institute of Medicine is now calling for.

PALCA: Okay, I think we have one more call before the break. Let's go to M.J.(ph) in Scottsdale, Arizona. M.J., welcome to the program.

M.J. (Caller): Hi. Thank you very much for taking my call.

PALCA: Sure.

M.J.: My question has to do with follow-up. I'm on certain medications that are continually misfilled, either the wrong dosage, the wrong type. It's a matter of OxyContin versus Percocet versus whatever line of drug might be in the pain field.

I literally am in my car because a pharmacy misfilled a prescription this morning, and I had to go back and get a new scrip in order to get the proper medication. What can the consumer do to follow-up when this is a continual problem? I am probably on my fourth or fifth pharmacy in my community trying to find one that can work with me consistently.

PALCA: Okay, M.J., let's see what Dr. Bates has to say because I'm sure this is an issue that came up in his report.

Dr. BATES: Absolutely. One of the strong recommendations in this report is that we need to begin to move to e-prescribing, in which providers in the outpatient setting as well as in the inpatient setting write prescriptions electronically and then they're transferred immediately and directly to pharmacies.

There are a lot of - lots of issues in which things get lost in the transfer today when something is sent from the doctor's office to the pharmacy. And if we can move to e-prescribing, it'll be possible to sort out some of those issues right at the time that the prescription is transmitted. So I think that there's a technical fix that's within sight on this one.

PALCA: Okay. We have to take a short break, but we're talking this hour about medication errors: what patients can do about them, what hospitals can do about them, what doctors can do about them. In a moment, we'll see if there's anything that the pharmaceutical industry thinks it can do about them.

So stay with us. We're taking your calls. Our number is 800-989-8255. That's 800-989-TALK. And we'll be back after a short break.

(Soundbite of music)


We're talking this hour about medical errors. My guests are David Bates, chief of the Division of General Medicine at Brigham and Women's Hospital, and Donald Berwick of the Institute for Healthcare Improvement.

And joining me now to talk more about the pharmaceutical industry's response to the Institute of Medicine report is Steven Lassman. He's senior assistant general counsel to the group PhRMA, that's the Pharmaceutical Research and Manufacturers Association - Pharmaceutical and Manufacturers of America. Scott Lassman, I'm sorry, Scott. And he joins me here in the studio. Thanks for talking with us today.

Mr. SCOTT LASSMAN (Senior Assistant General Counsel, Pharmaceutical Research and Manufacturers of America): My pleasure.

PALCA: Sorry. Steven doesn't sound - doesn't speak well for my ability to ask you intelligent questions, but, you know, getting the name right is important.

Mr. LASSMAN: I'll be Steve today, if you like.

PALCA: No, no, we'll stick with Scott, so - but that's actually - okay, so first of all, I mean, does the pharmaceutical industry have a role in this? It seems to me to some extent, you know, you make the medicines, you hand them off, and then it's up to others to use them properly.

Mr. LASSMAN: Well, we absolutely have a role in this. I mean, one of the things that we do is we provide the names for medications, and we take very seriously the responsibility to make sure that the names that are chosen do not have the ability to be confused with other names. So, you know, I think we clearly have a role here and we're very serious about that role.

PALCA: Well, how important is a name? I mean, we were looking through this. I mean, there certainly seem to be some drugs that sound very similar - Celebrex, Cerebyx, Celexa - well, certainly Celebrex, Cerebyx. I mean, those sound pretty similar to me.

Mr. LASSMAN: Well, some of the names are similar. I mean, the confusability is not just about whether the names sound alike but it also hinges on how the drug is used. So, you know, I can't really comment on those two drugs. But, for instance, you could have two drug products that sound very similar, but because they are used in very different contexts, or they may have, you know, it'd be different dosage forms - one may be a pill, one may be an injection, one may be used by outpatients, one may be used in a hospital. In that case, even though they may sound very similar, the chance that they're going to be confused is relatively low.

PALCA: I see. What do you make of the Institute of Medicine's conclusion that the patient has a much larger role to play in terms of making his or her own safety - taking care of that, acting as his own advocate?

Mr. LASSMAN: Well, I think everybody has a role to play here not just the patient but the manufacturer, physicians, pharmacies. I mean, it's really a system-wide problem, and I think it requires a system-wide solution.

PALCA: Okay, let's go back to the phones now and take a call, this time from Wally(ph) in Reno, Nevada. Wally, welcome to the program.

WALLY (Caller): Good afternoon, gentlemen.

PALCA: Good afternoon.

WALLY: I just wanted you to know that I am a employee of - I've been a registered nurse for 31 years. I - patient safety is one of the Veterans Administration's primary goals. I happen to work for the Veterans Administration in Reno, at the hospital.

We have a computerized medication system that allows us to only bring up the patient's profile. Well, every patient gets an ID band with a barcode on it. When I scan it, I - that ID band - I bring up my patient's profile. I can only give medications from that profile and that helps me...

PALCA: Right.

WALLY: not make mistakes.

PALCA: Sure, well, Donald...

WALLY: (unintelligible) As the person that gives the medicine, we don't want to injure our patients.

PALCA: Well, I'm glad to hear that. But, Donald Berwick, is that - the VA has had a pretty good track record in terms of patient safety, isn't that correct?

Dr. BERWICK: It's been terrific. It's been probably the large system in America that's done the most committed work toward trying to make patient care safer. As Wally said, they've introduced bar-coding, computerized physician, (unintelligible) entry, they have a computerized record system, and, more important than anything, they've had leadership. The central leadership there has for years now been thoroughly committed to safety as a priority.

I think Wally's comment makes a - it is very important to understand that this is not a problem of effort in the workforce. Asking doctors and nurses to try harder to be safe is not a solution. It's doing the kinds of things the VA has done, which is to redesign the care so that people like Wally can work in an environment that helps them be as safe as they want to be.

PALCA: Well, Dr. Berwick, you've got the ear of Scott Lassman, who's here, and he's got the ear of the pharmaceutical companies. Is there anything you would like to tell them about what else they could do that would help your efforts?

Dr. BERWICK: They're part of the leadership. The pharmaceutical committee has to come - community has to come to the table as thoroughly as anyone has. He said that risk is relatively low. That's good, but our aim should be zero, and I'd expect the pharmaceutical community to be completely committed to eliminating medical errors as a real goal for this nation.

PALCA: Is that a fair expectation, Scott Lassman?

Mr. LASSMAN: Well, I think we clearly are committed. We've been working with a number of national groups: the National Council on Patient Information, National Coordinating Council on Medication Error Reporting and Prevention. I mean, we clearly have been working on this problem. I agree that, you know, the goal should be zero medication errors. You know, whether that's a realistic goal, I don't know.

I would say, you know, tens of millions of patients use their medications everyday without problem, so, you know, people should not be worried. This is a huge problem, but it's certainly an important one and certainly one that we are working very hard to solve.

PALCA: Okay, let's go to Fred(ph). Fred in Fairbanks, Alaska. Welcome to the program.

FRED (Caller): Oh, good afternoon.

PALCA: Good afternoon.

FRED: I have had some recent personal experience in this matter. I was recently the advocate for my son who was in the hospital. And in this particular hospital, they had a computerized system where the patient's armband was scanned. They entered the profiles in the computer on each occasion. But there were a couple of incidents which demonstrated to me that the real problem was not the system, it was the lack of professionalism on the part of the staff.


FRED: For example, in this particular case, there was an antibiotic that was prescribed. It was the correct antibiotic. The right patient was determined. The right dose was determined. It was hung on the tree, but then the nurse was distracted and it was never connected.

PALCA: Right. Right. Maybe I could get Dr. Bates to respond to that because we know no one's trying to do that, but people get distracted. Is a computer system going to solve that problem, Dr. Bates?

Dr. BATES: Well, it's never going to be perfect, but bar-coding really does likely substantially increase the chances that the right patient will get the right drug at the right time. As Dr. Berwick mentioned earlier, though, we do have to work on our professionalism, and any of these interventions really only work if you have developed a culture of safety.

PALCA: Yeah. But I'm surprised to hear you say that because a culture of safety, it seems hard to believe that that's not already in place in most healthcare settings.

Dr. BATES: Well, you know, in many settings, the traditional approach has been to find the person who made the error and then to blame, and that really doesn't take you where you want to go.

PALCA: Right.

Dr. BATES: When you find an error, you need to deal with it, see why it happened, and then see what you could do to prevent it the next time around.

PALCA: Do you think that hospitals, or healthcare providers in general, have been as forthcoming as they ought to be to say, look, we did make a mistake, and we're going to try to fix it? Because a lot of times, I have a feeling that patients start feeling lousy, they go to the doctor, the doctor sees what the problem is, and says, oh, we can take care of that without ever explaining that it might be an improper medication.

Dr. BATES: I think that they've not been as willing to disclose that the medication was the problem as they perhaps should have been. Although I think things are - the tide is beginning to turn around that, and I think the 1999 report, the To Err Is Human report really did represent a sea change nationally in that regard.

PALCA: Okay. Let's take another call now and go to Alex(ph) in Fort Myers, Florida. Welcome to the program, Alex.

ALEX (Caller): Hi, thank you for having me on.

PALCA: Sure.

ALEX: I'm a registered nurse and actually a nursing supervisor. I've been doing that for about nine years. And, you know, one of the critical checks in a hospital system of course is the physician. He will write for the medication, the nurses check it, and most frequently the nurses are the ones that administer the drugs. And I haven't had - heard anyone really talk about - we talk about systems, and systems are good, but without the people to use those systems and, you know, have the time to use those systems it's really not helping.

And I guess what I'm pointing out is that the importance - right now, we're in a critical, critical nursing shortage. We have patient to nurse ratios of anywhere from eight to 13 patients, and when you're administering medications to that many folks, I think that with those high ratios, you really, really increase the risk of medication errors. And I'd like to hear what the panel has to say about that.

PALCA: Sure. Good question. Donald Berwick, what about that? How important is inadequate nursing staff?

Dr. BERWICK: It's very important. We have good evidence that nursing ratios do make a difference. But let's - I mean, let's understand that given any nursing ratio, it's possible to have safer or less safe systems. Alex is describing what's going on now, which is nurses working under enormous stress. We need to build dikes around their work so that they can be protected against their own human frailties. So I actually think the nursing shortage means we need to spend more attention to systems that really make things safe when people are under stress. That includes a lot of what this reports about and what Dr. Bates has been mentioning.

PALCA: One of the things, though, the systems that have to be put in place -Dr. Bates was talking about a system where, you know, a doctor writes a prescription and it automatically goes to a pharmacy, maybe it automatically goes on the patient's chart, which the patient carries around.

But the trouble seems to be there's lots of overlapping systems that people can have access to and, you know, there could be incompatibility so that you may have all that information, but you've done it in the IBM world, the PC world, and the system you're using is in the Mac world, the Apple world. So are we -is there a problem with compatibility in these systems?

Dr. BERWICK: It's a really serious problem. And first of all, remember Alex used the word write, which means we're still using handwriting. My pizza joint doesn't do that anymore, so we're behind in modernization.

Doing it in such a way that the systems are compatible, that they talk to each other, and that we finally commit as a nation to a computerized record is absolutely the must-have quality of the system. We've got to do that.

This report says that it wants, by 2010, all prescribers in pharmacies to be using electronic prescribing, and I'd go so far as to say electronic records. It's just time to do it.

PALCA: Dr. Bates, you think that's possible?

Dr. BATES: Absolutely, I do. There are some barriers that need to be dealt with for that to happen, but it is possible to move clinical information around today. We do have better and better standards for doing that, and that's going to help a lot in terms of safety.

PALCA: I'm wondering if I can ask you, Scott Lassman, if you - if there were this project to have this kind of a computerized network to prevent these kinds of errors, how would the industry respond to that?

Mr. LASSMAN: Well, we actually are working on that right now. We would be very supportive of an ePedigree solution, and there are work groups...

PALCA: What's an - what does that mean, ePedigree?

Mr. LASSMAN: I'm sorry, ePedigree. I mean e-prescribing. I'm getting mixed up with some of my other work responsibilities.

PALCA: That's all right.

Mr. LASSMAN: Yes, we're very supportive of an e-prescribing solution. Handwriting, I think, is probably one of the biggest problems here. When you talk about physician writing, just to give you an example, there have been claims that drugs like Capitin(ph) and Cozaar are two problem names.

I think anybody looking at those would say those are not similar at all, whether you look at it in written form or orally. The problem is they both begin with a C, and when you, you know, write in script, you do a big C and then, you know, a bunch of squiggles, they look alike. Is the problem the name or is the problem the handwriting? I think it really is the handwriting.

PALCA: We're talking about medication errors - how to prevent them, why they occur, and maybe what patients should or can or must do to protect themselves. I'm Joe Palca, and this is TALK OF THE NATION from NPR News.

And I'll tell you what. Let's take one more call now and go to Eric(ph) in Biden(ph) Lakeā€¦

ERIC (Caller): Hi, how are you doing. Thanks for having me on.

PALCA: You're welcome. Go ahead.

ERIC: I would just like to suggest that patients themselves should be very aware of what their condition is, and then when prescribed medication that you are provided a pharmacist who tells you about the medications and the side effects.

However, I feel like, you know, you have a responsibility to yourself to do some research on that as well. In my case, I am a veteran. I had my gall bladder out 15 years ago, and I kept getting stones in my bile duct, you know, which was hooked up to my gall bladder.

And about three years ago I was diagnosed with chronic persistent pancreatitis and biliary tract disease where I was producing stones about twice a year. And it got to the point to where my pain would not go away because it reached a chronic state. They tried a lot of narcotic medications on me, and they ended up giving me the Fentanyl patches, and they're very strong.

It's very hard to even function on - but I started going in to the hospital like once every two months having this terrible pain and everything. And they said well, you know, you're just going to have to deal with that. And I've been taking it for a year and a half.

So I started doing some more research on the medication and here's what I found. And I've just talked to my doctors about it and now they're getting me off of it, but it says - I got the vendor to send me some information and mine - I do have chronic pancreatitis.

Here's what it says. It says used in pacreatic and bilinary(ph) tract disease patients. Fentanyl transdermal systems cause spasms of the sphincter and should not be used in patients with chronic persistent pancreatitis or biliary tract disease. And those opioids in Fentanyl transdermal will cause an increase in the serum amylase concentration. And my amylase is always up, so...

PALCA: Okay, well Eric. I think...

ERIC: ...progressed to a worse stage, and that's where I am.

PALCA: Yes. No, I hear you. It sounds like a bad situation. But David Bates -is the patient - this is one of those cases where the patient says look, I had to do the research myself. But that something that seems to me is on the label. Wouldn't a doctor be able to catch that?

Dr. BATES: Well, that's the kind of thing that it's hard to remember. I think it's terrific that Eric did go and track that down himself. That's the kind of thing that, if I'm prescribing, I would like the computer system to warn me about.

I've used Fentanyl some and didn't know about that particular issue. But the problem that Eric has is a rare one and it's hard for doctors to keep track of all of those things.

PALCA: Okay, and one other thing that I wanted to ask you about in your report is you say that more information should be made available to patients. Who is in the best position to make that information available, do you think?

Dr. BATES: Well, today, there are a variety of different sites to get information, and anyone with access to the Internet can get lots of different information. The key is that it should be reliable and valid and we need ways to make sure that the information that people are going to really is useful information and reliable information.

PALCA: But who should vet that? Is it the government, is the companies, is it the hospitals? Is there a central place that it should be vetted?

Dr. BATES: Well, I think that's really not clear. I think it will come from a variety of sources and that we may go to the sort of approach where there's some sort of a stamp of approval.

PALCA: Okay. Well, I'm afraid that's where we're going to have to leave this discussion, and I apologize to all the people who have been waiting to talk, because it's obviously something that a lot of people can relate to.

I'd to thank my guests. David Bates is chief of the Division of General Medicine at Brigham and Women's Hospital. Donald Berwick is president and CEO of the Institute for Healthcare Improvement. And Scott Lassman is a senior assistant general counsel to the group PhRMA, the Pharmaceutical Research and Manufacturers of America. Thanks to all of you for joining me today.

Dr. BATES: Thanks for having me.

Mr. LASSMAN: Thank you, Joe.

Dr. BERWICK: It was a pleasure.

PALCA: When we come back, we'll be talking about a remarkable drug and some unfortunately possibly remarkable things that it may have wrong with it. So stay with us.

(Soundbite of music)


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