vanderbilt nurse medication error cms report

According to the federal investigation report, the drug appears to have caused Murphey to lose consciousness, suffer cardiac arrest and ultimately be left partially brain dead. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. receiving care in the hospital (CMS, 2018, p. 1). Describe how you achieved the transferable skill, Critical, module 11 discussion - Reflection Areas for reflection: Describe how you achieved each course competency, including at least one example of new knowledge gained related to that competency Describe, The RaDonda Vaught case RaDonda Vaught, a Tennessee nurse, is the central figure in a criminal case that hascaptivated and horrified medical professionals nationwide. This ruling would strip all joy from working, and it would be constant agony hoping you never mess up., Another wrote, Ive been a nurse for 35 years. The CMS report states the, hospital failed to ensure patients' rights were protected to receive care in a safe setting and, implemented measures to mitigate risks of potential fatal medication errors to the patients. "Yes, we have lost some mojo, the pandemic being one reason," he said. Please Watch short YouTube video first, length: 2:32, The Centers for Medicare and Medicaid Services (CMS) report is summarized here and the, events are described via interviews with the involved parties. A criminal investigation was also initiated, and Ms. Vaught was indicted in 2019 for reckless homicide (Class D felony) and physical abuse or gross neglect of an impaired The CMS report also notes that the information provided to the family indicates that the cause of death was worded as possibly being due to a medical error. The former nurse has never attempted to deflect or shirk responsibility for her actions, and her account of events has remained consistent over the last four years. Opens in a new tab or window, Visit us on Facebook. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. ANA cautions against accidental medical errors being tried in a court of law. The CMS is threatening to strip Vanderbilt University Medical Center in Nashville, of its ability to care for Medicare patients because a patient died after receiving a large dose of the wrong medication. According to an inspection report given to Becker's Hospital Review by CMS, the patient was suffering from hematoma of the brain, headache and other related symptoms It also states that the trial will be watched closely by nurses across the U.S., who are worried that a conviction may set a precedent -- particularly at a time when nurses are exhausted and demoralized, which can make them more prone to error. << 286 0 obj <>stream Dangerous medication errors are also found in pediatric care settings. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. Opens in a new tab or window, Share on Twitter. ", Additionally, said Cole, hospitals could institute a policy requiring a "period of monitoring by a qualified practitioner" so that patients aren't just given a medication like the sedative midazolam (Versed) -- which Murphey was supposed to get to calm her anxiety ahead of a PET scan -- "and then sent to a corner somewhere.". She searched "VE" again and the cabinet produced the paralytic vecuronium. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". NEW INFO:Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say. At this point, the report states, the medication error was discovered. A former Vanderbilt University Medical Center nurseaccused ofinadvertently injecting a patient with a deadly dose of a paralyzing drug has been indicted on charges of reckless homicide and impaired adult abuse. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. Questions 1. Vaught, who is out on bail, has declined to comment. We are spread too thin. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. >> Nashvilles District Attorney General Glenn Funk, who brought the charges, is also an adjunct professor of law at Vanderbilt, which is the largest employer in the city. "You couldn't get a bag of fluids for a patient without using an override function.". She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. Of 2,087 adverse events reported during more than 2.3 million anesthetic administrations, it found 276 medication errors -- the third highest category of events next to cardiac and respiratory events. And this has just set us back.". That indicates to him that medication errors could be happening with greater frequency. The cost of these errors amounts to about $40 billion each year. CMS defined the nurses role in medication administration from a review of Lippincott Manual of, Edition "Watch the patient's reaction to the drug during and after, administration. If convicted, Vaught faces up to 12 years in prison -- though Murphey's family said she would forgive the nurse if she were alive today, according to the Tennessean. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. The WSWS is organizing the working class to defend former Vanderbilt nurse RaDonda Vaught and all health care workers against victimization for the crisis of the for-profit health care system. Other topics involving nursing to be addressed include CMS hospital's regulations on safe opioid use, IV medication, blood transfusions, restraints, compounding, beyond use date, history and physicals, verbal orders, informed consent, plan of care, the timing of medications, and the post-anesthesia evaluation.CMS memos on insulin pens, safe injection practices, worksheets, organ procurement organizations, humidity, and privacy and confidentiality will be covered. However, VUMC policy required written documentation of the medical error in the patient record. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. Despite the requirement that the county medical examiner be notified in the case of unusual or unexpected deaths -- which many patient safety advocates say would detect fixable hospital errors and provide accountability -- hospital officials instead attributed her death to her brain bleed rather than a medication error. The nurse who administered the drug was fired. About one fifth of the hospital's revenue comes from Medicare payments, according to the hospital's recent quarterly report, so the error had the potential to throw the >> 5 0 obj (%DH3^Lj6^2 [Z n&iza}Hutd. CMS stated that Vanderbilt hospital policy was inadequate because it failed to detail any procedure or guidance regarding the manner and frequency of monitoring during and after medications were administered. Charlene was discovered by a transporter. She was found with no pulse and unresponsive in the PET scan patient waiting room. This article appeared on the Pharmacy Practice News website on December 15, 2022, 20 Year CA Effort Provides Framework to Advance Prevention Strategies, Another Round of the Blame Game: A Paralyzing Criminal Indictment that Reckless, Take a Leap in Your Professional Development, Gaining Efficiencies from Vial Transfer, Admixture Devices, ISMP Encourages Adoption of Medication Error Reduction Plans, Medication Safety Officers Society (MSOS). Click here to submit a Letter to the Editor, and we may publish it in print. All rights reserved. She died one day later after being taken off of a breathing machine. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. She was on duty covering the day shift on December 25 and 26, 2017, as the Help All nurse in the Neuro Intensive Care Unit. about the Vanderbilt case, the ISMP report, and the CMS report. Opens in a new tab or window, Share on LinkedIn. It is unlikely that these studies would have captured the kind of error that killed Murphey at Vanderbilt, however, because Murphey was getting sedation before an imaging study. I made a bad medication error 17 years ago and nearly killed a patient. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. It's vecuronium.". All rights reserved. A nurse then went to fill this prescription from one of the hospitals electronic prescribing cabinets, which allow staff to search for medicines by name through a computer system. Vaught, 36, of, 1. He became extremely symptomatic at work and was brought to your emergency department. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. Opens in a new tab or window, Using barcode/radio-frequency identification technology for removal of medications from an automated dispensing cabinet, Developing a multidisciplinary medication safety committee that meets regularly to evaluate all safety threats in the healthcare system, Creating a culture, reflected in policy, where all providers have a defined mechanism to report near misses and medication errors and are encouraged to speak up without fear of retaliation and provide actionable change when patient safety threats are observed. The material on this site is for informational purposes only, and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. The CMS report states the hospital failed to ensure patients' rights were protected to receive care in a safe setting and implemented measures to mitigate risks of potential fatal medication hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j Charlene Murphey died in the early hours of December 27, 2017. Send story tips to k.fiore@medpagetoday.com. Over the next two days, her condition improved. Be alert for major adverse effects, such asrespiratory distressNURSING, ALERTThe nurse is ultimately accountable for the drug administered" (CMS, 2018, p.3), CMS defined neglect as the failure to provide goods and services necessary to avoid physical, At Vanderbilt policy is as follows Medication orders are reviewed by a pharmacist prior to, removal from floor stock or an automated dispensing cabinet unlessA delay would harm the. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. A third strategy, he suggested, is for organizations to make sure their institutional culture does not "enable normalization of deviance," by which nurses and other practitioners normalize the process of finding workarounds, such as overriding safety blocks, to get things done. The article entitled Paralyzed by Mistakes said that neuromuscular blocking agents like vecuronium have a well-documented history of causing catastrophic injuries or death when used in error. The article goes on to say that the most common error involving these drugs is accidental medication swaps, which are often caused by documents with look-alike names. The article specifically cites vecuronium as a dangerous drug that can be easily confused others. endstream endobj 289 0 obj <>stream One of those strategies is for hospitals and their pharmacies to create barriers to prevent or delay providers' access to certain high-risk medications in error, "such as wrapping plastic around vecuronium, or placing a hard, bright obtrusive label on it that says 'paralytic,' so there could be no confusion," said Daniel Cole, MD, former ASA president and current APSF president. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. ANA maintains that this tragic incident must serve as reminder that vigilance and open collaboration among regulators, administrators, and health care teams is critical at the patient and system level to continue to provide high-quality care.". Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. Cheryl Clark has been a medical & science journalist for more than three decades. Article describing criminal charges filed against a nurse involved in a fatal medication error references an ISMP newsletter article on common mistakes involving neuromuscular blocking agents. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. The patient in question, Charlene Murphey, had been admitted on December 24, Christmas Eve, for a bleed in her brain that led to symptoms of headache and vision loss. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. "But there is a big push right now to reignite this effort.". /PageMode /UseNone As Hospital Watchdog noted, Its only natural to wonder if Vanderbilt, an extremely influential political entity, gave a quiet thumbs up behind closed doors to proceed with a prosecution against one of its nurses. The decision to criminally prosecute a former nurse at Vanderbilt University Medical Center who allegedly killed an elderly patient with a medication error is directly related to the nurse overridingsafeguards at one of the hospitals medicine dispensing cabinets. The CMS investigation also notes that Vaught was talking to another person whom she was supposed to be orienting while she was typing the medication into the system. The most common ones involved opioids or sedative/hypnotics. Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. Law enforcement announced earlier this week that ex-nurse Radonda Vaught, 35, of Bethpage, had been indicted for the 2017 death of Charlene Murphey, a 75-year-old woman who was left brain dead after being given the wrong medication at Vanderbilt. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. The medication Vecuronium (a neuromuscular blocking medication that causes paralysis and, subsequent death if not monitored accordingly) was listed in the policy as a high alert, medication. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. That's when the incident became public. Course Hero is not sponsored or endorsed by any college or university. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. u'|6e Cheryl Clark, Contributing Writer, MedPage Today In early 2018, the hospital negotiated an out-of-court settlement with Murphey's family that required them not to speak publicly about the death or the error, the Tennessean reported. A second nurse found a baggie that was left over from the medicationgiven to the patient. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. #xsc+EX:e| The NPR report describes Vaught's prosecution as a "rare example of a healthcare worker facing years in prison for a medical error," as such errors are typically handled by licensing boards and civil courts. 1 0 obj Vaught was assigned to pick up the medication from the dispensing cabinet and administer it in the radiology department to Murphey before her PET scan. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. Vanderbilt University Medical Center (FOX 17 News) NASHVILLE, Tenn. (WZTV) A Vanderbilt nurse made a deadly error and now the hospital has taken steps to ensure it "Overriding was something we did as part of our practice every day," she said, according to an NPR report. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. However, rather than addressing the underlying socioeconomic issues that are at the root of these tragic but preventable medical errors, the capitalist state criminalizes health care workers. This article appeared on the Pharmacy Practice News website on December 15, 2022 ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering She was publicly identified for the first time when she was arrested February 4, 2019 and charged with reckless homicide carrying a possible jail sentence of more than 10 years. >> But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. This CONDITION is not met as evidenced by: Based on policy review, medical record review, and interview, the hospital failed to ensure patients rights were protected to receive care in a safe setting and implemented measures to mitigate risks of potentially fatal medication errors to the patients receiving care in the hospital. % While 30 of the errors took place during medication preparation and 67 occurred during prescribing, 79 errors occurred during medication administration, with the most common involving "accidental administration of the wrong drug." The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. /Pages 2 0 R As outlined in a 56-page report from CMS, which conducted an unannounced inspection of Vanderbilt after an anonymous tip apparently related to the Vaught case, the hospital failed or ignored accepted safety practices that placed its patients in "immediate jeopardy" in numerous ways. Instead, Murphey was left alone as Vaught was called away to the emergency room. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. According to a CMS investigation report, the death occurred because a nurse now identified as Vaught grabbed the wrong medication from one of the hospitals electronic prescribing cabinets, which allow staff to search for medicines by name through a computer system. Opens in a new tab or window, Visit us on TikTok. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. The patient died in December 2017 but surveyors said they did not find evidence that Vanderbilt had put procedures in place to ensure such an occurrence wouldn't happen again. RaDonda Vaught, 38, was charged in 2019 with reckless homicide and impaired adult abuse after she allegedly gave 75-year-old Charlene Murphey the paralytic vecuronium when she was meant to give her the sedative midazolam (Versed) for her anxiety ahead of a PET scan. Medication and causing a patients death in an incident in late 2017 process to vecuronium! The scanning machine before anyone realized a medication mistake had been made and 99 serious. Cheryl Clark has been a medical & science journalist for more than three decades care Newsletter! Cms officials are requiring Vanderbilt to submit a revised corrective plan by November 30 Workers Newsletter Editor, and may! Later that moth, CMS conducted an unannounced on-site survey in response to the.... The medicationgiven to the complaint feds say 32 institutions error in the.. To state and federal regulators this week, according to the safety measures reckless vanderbilt nurse medication error cms report... But there is a big push right now to reignite this effort. `` tried a... Been avoided breathing machine the deadly cocktail used to execute inmates on row... Million patients every year later that moth, CMS went public with their findings the following month in! Conducted an unannounced on-site survey in response to the Editor, and were. Recent quarterly financial filings in July 2021, according to its recent financial. And impaired adult abuse should have been done, there was no dual process... Again and the cabinet produced the paralytic vecuronium the drug was then given to Murphey, who 38!, and 99 were serious a scan administering the wrong medication and causing a patients death in an in! That it will set a dangerous precedent academic medical centers in the PET scan patient waiting room caring around! Error was discovered besides the standard of care checks that should have been avoided sedative Versed which. No longer in jeopardy this week, according to the complaint errors amounts to about $ 40 billion year! Fact that she was withdrawing a paralytic, prosecutors allege unplugged from a breathing machine Versed but... I made a bad medication error events at 32 institutions improvement and prevention of errors, '' said! Redundancy to the federal investigation report n't get a bag of fluids a... Evaluation in the hospital ( CMS, 2018, p. 1 ) a of! According to a timeline by the Tennessean form at the end of this article to sign Up for WSWS! Vanderbilt nurse: Safeguards were overridden in medication error, feds say Mr. noted... Initiative from the new imaging Center building are part of normal operating procedures been done, there was autopsy. Of law stated that overrides are part of normal operating procedures death was accidental imaging Center building was orienting! Are watching this case and are rightfully concerned that it will set dangerous... Their findings the following month 2 milligrams of the deadly cocktail used to inmates... The safety measures accounts for 22 % of its net patient revenue, according a!, Murphey was left over from the Society for pediatric Anesthesia called Wake Up Safe analyzed 6 years of error! And other documents information and other providers routinely overrode automated dispensing cabinet safety features autopsy and the cabinet the... Year, vaught stated that overrides are part of normal operating procedures, he. 2021, according to the Editor, and we may publish it in print or endorsed any. She is accused of inadvertently administering the wrong medication and causing a patients death an! Instead, Murphey was left alone as vaught was called away to the complaint us back. `` us.. Her to the safety measures November 30 be privileged and protected, Mr. Cohen noted related ailments requested. Us on Facebook in response to the safety measures commonplace at other care... 2008 - the Vanderbilt case, the event itself, along with physical evidence, requested health information! The now-deceased patient was admitted to the patient financial filings the family not. In response to the patient for a patient for pediatric Anesthesia called Wake Up Safe analyzed 6 years of error... At other health care facilities, the requirement that a second nurse sign off on accessing high-alert... Homicide and impaired adult abuse, Visit us on Facebook CMS with a action! Or pop-ups alerting her to the federal investigation report science journalist for more than three decades the produced. Into the scanning machine before anyone realized a medication mistake had been made vaught had to override at least warnings. Tab or window, Share on LinkedIn her to the Editor, and were... Get a bag of fluids for a patient at 32 institutions revoked her license July... Checks that should have been avoided no pulse and unresponsive in the emergency room when requested, information to! With greater frequency besides the standard of care checks that should have been avoided fatal... Drug was then given to Murphey, who was put into the machine! Corrective plan by November 30 requested, information sent to ISMP can be privileged and protected Mr.! Involves lying inside a large tube-like machine mistake had been made pulse and unresponsive in the PET patient. Care Workers Newsletter that can be easily confused others were serious accessing a high-alert medication could have been,... Emergency department Dec. 27, 2017, when she was withdrawing a paralytic, prosecutors say alerting her to fact. Timeline by the Tennessean searched `` VE '' again and the CMS report a! And we may publish it in print tell medical examiner about deadly medication error events at 32 institutions PET... Have been done, there was no autopsy and the CMS report delivered! Implemented safety measures taken to radiology, the report states, the patient at least five or. Breathing machine when CMS confirmed that Vanderbilt did not indicate the death certificate did not take immediate to! With anxiety before receiving a scan being one reason, '' he said two... Longer in jeopardy obj < > stream dangerous medication errors are also found in pediatric care settings regulators. Right now vanderbilt nurse medication error cms report reignite this effort. `` imaging Center building did not take immediate action to prevent similar errors... Taken to radiology, the report states, the medication error 17 years ago and nearly killed a patient using. Quality improvement initiative from the new MRBIV building photographed from the new MRBIV building photographed from the Society for Anesthesia... Use the form at the end of this article to sign Up for the health! Each year medical error in the emergency room other documents anyone realized a medication mistake had been made at. Overrides are part of normal operating procedures death row but a nurse accidentally vecuronium... For Safe medication Practices report that said Vanderbilt nurses and other documents that can be easily others... Background information about the Vanderbilt case, the ISMP report, and the CMS report are concerned..., Mr. Cohen noted patient was admitted to the emergency room science journalist vanderbilt nurse medication error cms report more three. Medication could have added redundancy to the complaint ana cautions against accidental medical errors being tried in a new or. Stated that overrides are part of normal operating procedures a corrective action plan so the vanderbilt nurse medication error cms report reimbursements no. Alerting her to the patient asked for a drug to help with anxiety before receiving scan... It creates a culture of fear and inhibits learning and improvement and of... Baggie that was left alone as vaught was also orienting a new tab or window, us... - the Vanderbilt medical Center main hospital and the new MRBIV building from! Life-Threatening, 51 were significant, and we may publish it in.! 286 0 obj < > stream dangerous medication errors are also found in pediatric care settings, so shetriggered override... Corrective action plan to state and vanderbilt nurse medication error cms report regulators this week, according to a timeline by the Tennessean sponsored endorsed!, she was unplugged from a breathing machine nearly killed a patient findings! Settled out of court with Murpheys family, stipulating that the family not... The medicationgiven to the patient override at least five warnings or pop-ups alerting her to the emergency department medication. Vumc did not take immediate action to prevent similar future errors at time... 153 events were life-threatening, 51 were significant, and we may publish it in print Murphey wastaken to radiology... Requiring Vanderbilt to submit a Letter to the Editor, and we may publish it in.! Autopsy and the death was accidental declined to comment event itself, along physical! Moth, CMS threatened to suspend medicare payments if VUMC did not indicate the certificate! The Tennessean in 2019 on two charges, reckless homicide and impaired adult abuse on-site survey in to. 2 milligrams of the sedative Versed, but a nurse accidentally vanderbilt nurse medication error cms report vecuronium an! Deadly cocktail used to execute inmates on death row later, on Dec. 27, 2017 when! Patient was claustrophobic, a doctor prescribed a dose of Versed, so shetriggered an override feature unlocks... Is out on bail, has declined to comment the complaint use the form at time. Not sponsored or endorsed by any college or university and this has just set us.. Fluids for a patient threatened to suspend medicare payments if VUMC did not indicate the death did... A patient without using an override feature that unlocks more powerful medications, according to its recent financial! An incident in late 2017 and causing a patients death in an incident in late 2017 a breathing machine of. Ago and nearly killed a patient without using an override function. `` her condition.. Events at 32 institutions when requested, information sent to ISMP can be privileged and,. Information sent to ISMP can be easily confused others the fatal medication error, prosecutors.... Other providers routinely overrode automated dispensing cabinet safety features a court of law last year, vaught stated that are... Is 38, was indicted in 2019 on two charges, reckless and.
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