prescription errors in pharmacy

Available at: https://improvement.nhs.uk/documents/3121/Patient_Safety_Alert_-_Resources_to_support_safe_management_of_hyperkalaemia.pdf (accessed February 2019), [27] European Medicines Agency. To do this, use reliable methods to verify a patient’s identity when the prescription is entered in the computer. Reducing harm from omitted and delayed medicines in hospitals in 2010. You will be re-directed back to this page where you will have the ability to comment. In addition to incorrect dosage and the wrong medication, other common pharmacy errors include: Failure to identify harmful drug interactions Failure to provide adequate information regarding the drug Failure to warn of potential drug allergies Available at: https://www.sps.nhs.uk/articles/ npsa-alert-preventing-fatalities-from-medication-loading-doses-2010 (accessed February 2019), [39] NHS England. Prescription and dispensing errors can happen when a pharmacist is writing the prescription, giving out the wrong drugs or the wrong medication has been prescribed. A pharmacy filling 250 prescriptions a day averages four mistakes. Thank you for sharing information so … The majority of patient safety incidents identified in community pharmacy are medication related, e.g. 2012. 2018. Errors associated with electronic prescriptions can often lead to workflow disruptions. Special report: Getting a good pre-registration placement, Special report: Treating common minor ailments in the pharmacy, ONtrack - Pharmacy revision for preregistration trainees, Pharmacy Knowledge – Digital learning for students, Pharmacy reference and learning resources, Scottish National Pharmacy Board meetings, , February 2019, Vol 302, No 7922, online |, Evaluation of the Royal Cornwall Hospitals NHS Trust community pharmacy transfer of care around medicines service, Misuse of prescription and over-the-counter drugs to obtain illicit highs: how pharmacists can prevent abuse, Pharmacist contributions to consultant-led post-take ward rounds: a service evaluation, Community pharmacist-led influenza vaccination: a service evaluation, Evaluation of a pharmacist-led virtual thiopurine clinic, Evaluating pharmacist interventions using the Simpler tool in Malaysian patients with type 2 diabetes, Dilemma: when a line manager takes credit for your work, Pharmacists can take the lead in public reassurance on COVID-19 vaccines, RPS says, Give provisionally registered pharmacists all the support you can, RPS urges employers, RPS and PSNC call for law change to ensure ongoing access to full Summary Care Record, Botanical illustration of Citrus vulgaris, 1880, RPS meets with government to discuss pharmacists amending prescriptions during medicines shortages, Aston University first in UK to subscribe to Pharmacy Knowledge, https://www.gmc-uk.org/-/media/documents/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf, https://www.gmc-uk.org/-/media/about/investigatingtheprevalenceandcausesofprescribingerrorsingeneralpracticethepracticestudyreoprtmay2012.pdf?la=en&hash=62C1821CA5CCC5A4868B86A83FEDE14283686C29, http://www.eepru.org.uk/wp-content/uploads/2018/02/eepru-report-medication-error-feb-2018.pdf, https://mdujournal.themdu.com/issue-archive/issue-5/prescription-errors, 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https://www.gosportpanel.independent.gov.uk/media/documents/070618_CCS207_CCS03183220761_Gosport_Inquiry_Whole_Document.pdf, https://www.sps.nhs.uk/wp-content/uploads/2018/02/NRLS-1066-Opioid-Medicines-RRR-2008-07-04-v1.pdf, https://www.sps.nhs.uk/articles/what-are-the-equivalent-doses-of-oral-morphine-to-other-oral-opioids-when-used-as-analgesics-in-adult-palliative-care-2/, https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/national-diabetes-inpatient-audit-nadia-2017, https://www.sps.nhs.uk/articles/npsa-alert-the-adult-patients-passport-to-safer-use-of-insulin-2011/, https://www.diabetes.org.uk/resources-s3/2017-10/InsulinSafety.pdf, https://www.diabetes.org.uk/resources-s3/2017-10/Improve%20the%20management%20of%20inpatients%20on%20insulin%20final_0.pdf, https://improvement.nhs.uk/documents/3121/Patient_Safety_Alert_-_Resources_to_support_safe_management_of_hyperkalaemia.pdf, https://www.ema.europa.eu/documents/medication-error/insulins-high-strength-guidance-prevention-medication-errors_en.pdf, https://cks.nice.org.uk/nsaids-prescribing-issues#!scenario, https://www.sps.nhs.uk/wp-content/uploads/2017/12/Drug-monitoring-2017.pdf, https://www.sps.nhs.uk/articles/npsa-alert-safer-lithium-therapy-2009, https://www.sps.nhs.uk/articles/npsa-alert-improving-compliance-with-oral-methotrexate-guidelines-2006/, https://bnf.nice.org.uk/interaction/introduction.html, https://www.sps.nhs.uk/articles/ npsa-alert-preventing-fatalities-from-medication-loading-doses-2010, https://improvement.nhs.uk/documents/496/Patient_Safety_Alert_-_Risk_of_error_with_injectable_phenytoin_v2.pdf, https://bnf.nice.org.uk/treatment-summary/oxygen.html, https://www.sps.nhs.uk/articles/archived-sept-2015-rrr006-oxygen-safety-in-hospitals-d-npsa-d-september-2009, Essentials of Economic Evaluation in Healthcare, Everything you need to know about the COVID-19 therapy trials, Everything you should know about the coronavirus outbreak, One in ten hospital trusts have been asked to approve unlicensed cannabis-based medicinal prescriptions, Government impact assessment of pharmacy contract warned it could cause closures, Pharmacies will ‘struggle’ to serve patients if NHS Test and Trace fails to look at individual cases, warns negotiator, Ward-based pharmacy services help reduce high-risk prescribing errors in hospitals, report concludes, Hunt announces proposals to reduce medication and prescribing errors, Electronic prescribing does not prevent most harmful paediatric prescribing errors, study finds, How our hospital reduced its paracetamol overdose prescribing errors to zero, Pharmaceutical Journal Jobs Terms and Conditions, Pharmaceutical Journal Subscription Terms and Conditions, Review medicine procedures to identify a list of critical medicines where timeliness and continuity of administration is important (e.g. Owing to the small sample sizes used in observational studies, it is difficult to identify the full range of prescribing errors that are responsible for medication incidents or adverse event reports with outcomes of death, or severe harm and/or medical indemnity claims. Community pharmacy oral anticoagulant safety audit. Available at: https://cks.nice.org.uk/nsaids-prescribing-issues#!scenario (accessed February 2019), [30] Avery AJ, Rodgers S, Cantrill JA et al. 2016. Available at: https://www.sps.nhs.uk/wp-content/uploads/2018/02/NRLS-1066-Opioid-Medicines-RRR-2008-07-04-v1.pdf (accessed February 2019), [20] Cousins D, Gerrett D & Warner B. Patient safety alert. Source: Lewis Houghton / Science Photo Library, Prescribing errors have been estimated to cost the NHS £98.5m per year. Available at: http://www.eepru.org.uk/wp-content/uploads/2018/02/eepru-report-medication-error-feb-2018.pdf (accessed February 2019), [5] NHS Resolution. This was clearly written in the clinic letter. According to one 2016 study, “It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings.”It’s the responsibility of all pharmacy workers to report any issues that are going on. 2011. Member of the Community Pharmacy Patient Safety Group. Experts say there's very little data. Opioid medicines include diamorphine, morphine, codeine, fentanyl, oxycodone and methadone. Improper Drug Strength, Dosage Errors: Another common pharmacy error is that when the pharmacist fills the prescription, they do so with the wrong strength dosage. Pharm J 2015;295(7878):185–187. The last documented international normalised ratio (INR) for a patient on warfarin was noted more than a year ago. The patient was seen by many doctors and pharmacists, but no gastric protection was prescribed until after the patient had undergone surgery for a perforated ulcer. In primary care, patients with diabetes should have regular reviews, including discussions on any changes in their insulin treatment. 2009. 3 Even one error that sends a patient to the hospital or causes a death is too many, so take every opportunity to minimize the possibility of an error. Available at: https://mdujournal.themdu.com/issue-archive/issue-5/prescription-errors (accessed February 2019), [7] NHS Improvement. 2017. The patient had been given the wrong prescription, resulting in hypoglycaemia, which was reversed with intravenous dextrose[9]. 2006. Clinical Knowledge Summaries: NSAIDs — prescribing issues. An interesting read. Final report: An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. Although it was clearly documented in the notes that the patient’s target saturation range should be kept at 88–92%, oxygen was not prescribed. The patient should be informed of what has been documented in their records, so they are able to recall all the necessary information, including the name of the drug and the nature of the allergy. The I-Team has learned that there are more than 2.3 million prescription drug dispensing errors made each year in pharmacies across the U.S. Involvement of the pharmacist in reviewing the prescription and alerting the physician has minimized prescription errors to a great degree in our hospital setting. A practical guide to the use of pharmacokinetic principles in clinical practice. EQUIP study. 2017. The adult patient’s passport to safer use of insulin. Burden of medication errors in the NHS in England: Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. Pharmacy Error Lawyer helps people who have been the victim of prescription and medication errors. I wasn't aware that for mirtazapine may need a regular blood tests, but patients should be monitored for signs of agranulocytosis or severe neutropenia such as sore throat, or other signs of infection or a low WBC; ; for renal and hepatic function; also for signs/symptoms of serotonin syndrome or unusual changes in behavior. 2010. Dr Stephen Drage, director of investigations at HSIB, said at the time: “ePMA systems are a positive step for the NHS – research shows if implemented well they can reduce medication errors by 50%. The clearance of mirtazapine may be decreased in patients with moderate to severe renal impairment (creatinine clearance. Prescribing procedures should be reviewed to ensure they describe how medicine interactions are screened, by the prescriber and others, using specified information resources. A patient was admitted with an acute episode of COPD and type 2 respiratory failure. After taking four doses of MST, the patient was confused, hallucinating and drowsy. When readmitted, the patient was still on the loading dose of amiodarone. Out of 5000 prescriptions 176 drug related prescription error was found. Medication errors are common in pharmacy, but mistakes can lead to severe consequences, ranging from illness to death. The concentration of oxygen required depends on the condition being treated; the administration of an inappropriate concentration of oxygen can have serious or even fatal consequences[40]. doi: 10.1016/S0140-6736(11)61817-5, [31] Specialist Pharmacy Service. occurring prescription errors include incorrect selection of medication for the patient including the dose, quantity, indication, or the prescribing a contraindicated medication.2 Community pharmacists have an important role in detecting, preventing, and solving Dispensing errors include any inconsistencies or deviations from the prescription order, such as dispensing the incorrect drug, dose, dosage form, wrong quantity, or inappropriate, incorrect, or inadequate labeling. Lack of awareness of expiration dates Available at: https://www.sps.nhs.uk/wp-content/uploads/2018/02/PH035-Direct-Acting-Oral-Anticoagulants-DOAC-v3-Dec-16-8-1s1.2.d-2s1.1.d.pdf (accessed February 2019), [18] The Gosport Independent Panel. severe, moderate, mild and unknown) and the level of evidence (i.e. 3 Also, confusing or inadequate directions for use, incorrect or inappropriate preparation, packaging, or storage of medication prior to dispensing are considered to be errors. Further information can be added as prescription notes detailing monitoring requirements and can act as a prompt for colleagues when issuing prescriptions; Community pharmacy teams should check that patients who have been prescribed medicines that require monitoring are actually receiving the necessary monitoring. Covers a range of non-medicinal products suitable for use at home. DOI: 10.1211/PJ.2019.20206123, Unsuitable or offensive? The patient was discharged from a cardiology clinic with 200mg amiodarone three-times daily for one week, after which it would then be reduced to 200mg once daily. A patient was discharged following an ischaemic stroke. Response to freedom of information request for prescribing error incidents reported for 2017. An introduction to economic evaluation specific to healthcare, for those with little or no knowledge of economics. Key safety checks Prescription drop-off. Patient safety alert. Receiving The Wrong Medication Accounts for More Than 40% of Prescription Errors. 2018. The CPOE system has prevented and alerted the prescriber and pharmacist to dosage errors and allergies. NICE guidelines state that drug allergy status should be documented in medical records (including community pharmacy patient medication records) as soon as possible using defined terms: ‘drug allergy’, ‘none known’ or ‘unable to ascertain’, If a drug allergy is present, record all of the following: the drug’s name; the signs, symptoms and severity of the reaction; and the date when the reaction occurred. Practice Pharmacist, Lister House Surgery, Derby, UK. 2018. Pharmacists performing a clinical check of all prescriptions as part of their clinical duties, and when dispensing medicines, is an important safeguard to minimise the risk of prescribing errors. If you have been harmed by pharmacy mistake or prescription medication error, our lawyers will listen to the details of your case and advise you on how to best proceed. doi: 10.3399/bjgp13X670679, [4] Elliott RA, Camacho E, Campbell F et al. Call a pharmacy negligence lawyer. There were 35 medical negligence claims resulting from prescribing errors closed by NHS Resolution in 2017–2018, costing just under £4m[5]. The authors of the study concluded that pharmacy dispensing errors are a problem on a national level, at a rate of about 4 errors per day in a pharmacy filling 250 prescriptions daily. In addition, giving the wrong drug and administering a drug through the wrong route were each responsible for another 16 percent of all fatal medication errors. Patient safety alert. Prior to this, the patient was using tramadol 50mg three times per day for analgesia. Medical malpractice occurs when your medical care provider doesn’t use the amount of care that a skilled professional ought to use in any given situation. More than 7,000 people die in New Jersey and around the country each year from medication errors made by their local pharmacy. It is important for technicians to follow system-based processes and inform the pharmacist whenever they have questions or concerns or believe that processes do not work or are unmanageable. Service Level Agreement (SLA) - for the provision of Pharmacy services to the Trust National Reporting and Learning System (NRLS) - Central database of patient safety incident reports. Unfortunately, they had not been prescribed clopidogrel on discharge. Medication errors & pharmacy dispensing errors happen. Rapid response report. This evidence scan examines A concise, easy-to-read guide for healthcare professionals who encounter drug abuse. Prescription errors can occur in a variety of different circumstances. The prescription stated that the patient was allergic to Septrin® (Aspen) and penicillin. A study of dispensing errors in 2003 found that 3% of new prescriptions had associated dispensing errors, which, extrapolated to the number of prescriptions written annually, would represent more than 45 million dispensing errors on an annual basis. 23 November 2018, [8] National Patient Safety Agency. Correct data for patient, prescriber, and pharmacy identity are critical. Cookies are small text files stored on the device you are using to access this website. Check whether you have taken advantage of these ways to reduce errors: 2008. A drug-monitoring plan should be documented when first prescribing the medicine. /news/preventing-medication-errors-in-pharmacy, Copyright Specialty Pharmacy Times 2006-2019, 2 Clarke Drive Suite 100 Cranbury, NJ 08512 P:609-716-7777 F:609-716-9038. Patients should be contacted urgently if anticoagulant therapy is discontinued for this reason and the clinical consequences should be fully explained; Ensure procedures are in place in hospitals to identify when supplementary medicine charts (e.g. prescribing or dispensing errors. The outpatient prescriptions retained at the pharmacy from November to December 2017 were used to evaluate prescription patterns and errors. Drug errors in England cause appalling levels of harm and deaths, Health Secretary Jeremy Hunt says, as data suggests mistakes are being made. Available at: https://webarchive.nationalarchives.gov.uk/20171030132153/http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/medication-safety/?entryid45=61625&p=2 (accessed February 2019), [9] National Patient Safety Agency. Available at: https://improvement.nhs.uk/documents/496/Patient_Safety_Alert_-_Risk_of_error_with_injectable_phenytoin_v2.pdf (accessed February 2019), [40] National Institute for Health and Care Excellence. anti-infectives in sepsis or adrenaline in anaphylaxis), Make changes to systems for prescribing, supply and administration of critical medicines, both within normal hours and out-of-hours, to minimise risks. Available at: https://www.gmc-uk.org/-/media/about/investigatingtheprevalenceandcausesofprescribingerrorsingeneralpracticethepracticestudyreoprtmay2012.pdf?la=en&hash=62C1821CA5CCC5A4868B86A83FEDE14283686C29 (accessed February 2019), [3] Avery AJ, Galeb M, Barber N et al. Medication labeling errors are preventable and a company that subjects anyone to a medication injury must be held accountable. 1 There are inherent risks, both known and unknown, associated with the use of medica-tions (prescription and nonprescription). Other errors included … The total of 770 prescriptions were reviewed. Resources to support safe and timely management of hyperkalaemia (high level of potassium in the blood). Available at: https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/national-diabetes-inpatient-audit-nadia-2017 (accessed February 2019), [23] National Patient Safety Agency. The FDA enhanced its efforts to reduce medication errors by dedicating more resources to drug safety, which included forming a new division on medication errors at the agency in 2002. Taking the wrong medication or the wrong dosage can be harmful. n Medication errors n Multimorbidity nransitions of careT Tools and technology n Electronic tools WHO is committed to tackling the challenges of patient safety in primary care, and is looking at practical ways to address them. Some parts of the site may not work properly if you choose not to accept cookies. 2017. doi: 10.1136/bmjopen-2016-013647, [14] Specialist Pharmacy Service. 2009. Diabetes UK has produced guidance on improving insulin safety in hospitals. If patients are noncompliant with monitoring, GPs should be advised to suspend further prescriptions for anticoagulants until monitoring is up to date. 2017. However, they may be required to follow pharmacy policies that, due to legal concerns, may not encourage pharmacy staff to apologize for the error, explain how it happened, or share what will be done to avoid similar errors in the future. It's a good idea to let the pharmacy know they messed up. Available at: https://bnf.nice.org.uk/interaction/introduction.html (accessed February 2019), [37] National Institute for Health and Care Excellence & The British National Formulary. Improving guidance on oral methotrexate guidance. Procedures must clarify the healthcare professional responsible for counselling patients on newly prescribed anticoagulant therapy in individual clinical areas; Where GP surgeries are not responsible for ongoing INR monitoring, advice should be taken from secondary care anticoagulant clinics. According to an article published by Mount Sinai Medical Center, the top 5 common mistakes patients make with their prescription drugs are as follows: 1. Lancet 2012;379(9823):1310–1319. and NHS England, Superintendent Pharmacist, PCT Healthcare Limited, Chesterfield. Medical Malpractice Claims Against a Pharmacy for Medication Errors. Oral warfarin, the newer direct-acting anticoagulants, injected heparin and low-molecular-weight heparins have all been involved in reported prescribing error incidents that have caused death and serious harm[7],[8],[9]. Response to a freedom of information request for prescribing error claims data. With pharmacies being pressed to use a universal patient identifier, a third party data company is the answer to avoid to meet these new mandates and demands. Pharmacy negligence resulting in mislabeled prescription bottles can result in devastating consequences. In addition, the patient was on anti­biotics known to change digoxin levels[7]. BMJ Open 2017;7(3):e013647. Res Social Adm Pharm. Available at: https://www.sps.nhs.uk/wp-content/uploads/2017/09/Oral-anticoagulant-safety-audit-Sept-2017-vs1a.pdf (accessed February 2019), [16] Specialist Pharmacy Service. Electronic prescribing and dispensing systems should be configured to aid identification of critical medicines; Prescribers should communicate to other healthcare professionals, the patient and carers when an urgent prescription has been written and requires dispensing and administration. For newly initiated long-term medicines, guidance on drug monitoring should be included in GP letters and/or shared care guidelines should be used; Set up patient ‘recalls’ in GP systems for when blood tests are due. Pharmacists and healthcare professionals need to recognise and understand which drug interactions can result in significant patient harm. According to the same report published by the University of Connecticut, prescription labels with incorrect directions are the most frequent type of errors. Available at: https://www.sps.nhs.uk/articles/npsa-alert-the-adult-patients-passport-to-safer-use-of-insulin-2011/ (accessed February 2019), [24] Diabetes UK. It is important that any medicines the patient is taking are documented in these systems so that electronic and/or manual checks can be performed. Drug name confusions. Available at: https://www.diabetes.org.uk/resources-s3/2017-10/Improve%20the%20management%20of%20inpatients%20on%20insulin%20final_0.pdf (accessed February 2019), [26] NHS Improvement. 2014;10:837-852. The COPD admission treatment bundle was not used. 2014. Gaunt MJ. Available at: https://www.sps.nhs.uk/wp-content/uploads/2011/08/Implementing-Patient-Safety-Alert-18-anticoagulant-therapy-resource-May-2018.pdf (accessed February 2019), [15] Specialist Pharmacy Service. Tools to support local implementation. In the hospital with paper‐based prescriptions, 3714 medication errors were found: 288 (7.8%) prescription errors and 3426 (92.2%) dispensing errors. The patient was admitted to the intensive therapy unit where they deteriorated and died[7]. 2018. As more and more states require prescribers and dispensers of controlled substances to review a patient’s prescription monitoring program (PMP) history prior to prescribing or dispensing, errors in reporting to PMPs can cause a problem. For a free consultation, contact us online or call (312) 313-2888 . Rapid response report. You included mirtazapine as an example of medicines that require monitoring. Guidance on prevention of medication errors with high-strength insulins. Gosport War Memorial Hospital: The report of the Gosport Independent Panel. Pharmacy errors are preventable. Rapid response report. Available at: https://www.gmc-uk.org/-/media/documents/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf (accessed February 2019), [2] Avery T, Barber N, Ghaleb M et al. The average number of drugs per encounter was 3.2. 2. 2009. Medication errors are one of the most common causes of patient harm and prescribing accounts for a large proportion of medication errors. This was not noticed by the GP or pharmacist[38]. 4. 2018. An attempt to gain additional insight on how medication errors are managed was met with the inability of many pharmacy corporations to provide meaningful information. #Brazil Community Pharmacies Pharmaceutical Care Public Health Type 2 Diabetes #Community Pharmacy Drug Safety Medication Errors Pharmacy Practice #Drug Prescription Hospital Medication Errors Rational Use #Public Health. Being mindful and speaking up if things aren’t working is the best way to fix any errors before something bad happens. They collapsed and arrested shortly afterwards. It can help further document your claim in case you have any injury from their mistake. 26 November 2018, [6] Wratton C. Prescription errors. Patient safety alert. Odukoya OK, Stone JA, Chui MA. Prescribing errors affect patient safety, but pharmacists and other healthcare professionals can reduce the risk of them occurring. study, anecdotal or theoretical)[36],[37]. Medicines can do a lot of good but they also have the potential to cause harm are one of the most common causes of patient harm and prescribing accounts for a large proportion of prescription error. Transcription errors, such as inaccuracies and omissions make up approximately 15 percent of all prescription dispensing errors. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packa… Contact the prescriber if the starting dose is too high or if the dose has increased by 50% or more from previous dose; Remember that underdosing may also cause harm. A “notable number” of medication errors involving direct oral anticoagulants occurred in the first quarter of 2019, according to the National Pharmacy Association’s Medication Safety Officer update for … These types of errors can occur at any point during the process of selecting, prescribing and dispensing medications. Pharmacy Errors – Do You Have a Lawsuit? Medication errors that result in pharmacies dispensing the wrong medication occur when your doctor has prescribed you the right medication, but the pharmacist or pharmacy technician fills the prescription … These errors are easy to reduce. The patient was given 3L of uncontrolled oxygen throughout the night, with blood saturation recorded at 97–98% with no attempt to down-titrate their oxygen. This can be delegated to pharmacy teams within the general practice to follow up on; When dispensing prescriptions for medicines with loading doses, query with prescribers when unexpectedly high doses are prescribed or higher-than-normal doses are continued. Protocol for appropriate prescribing of direct acting oral anticoagulants (DOACs) and management of haemorrhage in surgical patients. Based on pharmacy personnel communication with prescribers, they noted several reasons for incorrect selection of information. These professional standards have been developed by the RPS, APTUK and the Pharmacy Forum of UK with the support of an expert steering group and public consultation, they describe good practice and good systems of care for reporting, learning sharing, taking action and review of incidents as part of a patient safety culture. Michelle Woods, American Pharmacy Purchasing Alliance. How to minimise the risks of medication errors with rivastigmine patches Published 29th March 2019.

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