ISSN: 2581-4265
Archives of Nursing Practice and Care
Research Article       Open Access      Peer-Reviewed

Patient Safety Culture in a Tunisian Teaching Tertiary Care Hospital

Mohamed Ben Rejeb1,2*, Dhekra Chebil1, Latifa Merzougui1,2, Balsem Kacem3, Selwa Khefacha-Aissa1, Lamine Dhidah1,2 and Houyem Said-Laatiri1,2

1Department of Prevention and Care Safety, Sahloul Hospital, Sousse, Tunisia
2Department of Community and Preventive Medicine, Faculty of Medicine of Sousse, University of Sousse, Tunisia
3Department of Pharmacy, Sahloul Hospital, Sousse, Tunisia

*Corresponding author: Mohamed Ben Rejeb, Department of Prevention and Care Safety, Sahloul Hospital, Sousse, Tunisia, Tel: +216 54 098 709; Fax: +216 73 367 451; E-mail: mohamed_benrejeb@yahoo.fr

Received: 27 July, 2017 | Accepted: 30 August, 2017 | Published: 31 August, 2017
Keywords: Patient safety; Safety culture; Hospital staff

Cite this as

Rejeb MB, Chebil D, Merzougui L, Kacem B, Khefacha-Aissa S, et al. (2017) Patient Safety Culture in a Tunisian Teaching Tertiary Care Hospital. Arch Nurs Pract Care 3(1): 077-083. DOI: 10.17352/2581-4265.000030

Objectives: Our study aimed to investigate patient safety attitudes and perceptions amongst health care providers in Tunisian tertiary care hospitals.

Methods: This cross-sectional study was conducted during April May and June 2015 in Sahloul University hospital in Sousse: a 630-beds tertiary hospital in Eastern Tunisia. This survey included 344 cares providers. The French version of the Hospital Survey on Patient Safety Culture questionnaire was used to identify dimensions of patient safety culture.

Results: Areas with potential for improvement were overall perception of security, Teamwork within units, organizational learning/continuous improvement, open communication and underreporting of events. Teamwork across hospital units had the lowest score. No significant differences between physicians and nurses were found for all composites in our study.

Conclusion: Patient safety culture remains underdeveloped in our hospital. Leaders must implement a development strategy by creating the culture and commitment needed to identify and solve underlying systemic causes related to patient safety.

Introduction

In developed countries patient safety is now recognized as a top priority in their healthcare systems [1]. Patient safety aims to protect patients against care-associated adverse events (AEs). They are defined as unintended injuries or complications caused by health care management, rather than by the patient’s underlying disease and that lead to death, disability at the time of discharge or prolonged hospital stay [2]. While, 35 to 70% of AEs have been judged to be preventable [3-5], they appear to be responsible for 44,000 to 98,000 accidental deaths and over one million excess injuries each year [6,7]. The situation is thought to be more challenging in developing countries with higher risk of patient harm due to the limitation of resources and lack of adequate infrastructures [8].

One aspect of patient safety that has been increasingly of interest is the “culture” of safety. Patient safety culture is defined as the product of individual and group values, attitudes, perceptions, competencies, and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organization’s safety management [9]. A positive patient safety culture guides the behaviours of healthcare professionals towards viewing patient safety as one of their highest priorities [9]. Safety culture assessment surveys allow hospitals to identify the strengths and weaknesses of their safety culture [10]. Literature review showed that quantitative methods using individual self-administered questionnaires were the most common [9]. Among these questionnaires, The Hospital Survey on Patient Safety Culture (HSOPS) of the Agency of Healthcare Research and Quality (AHRQ) is the most used tool to assess safety culture [11].

In Tunisia, awareness of patient safety seems to be delayed by contribution to developed countries. Few studies were conducted to examine the prevalence of AEs and assess safety culture in Tunisian hospitals [12-14]. In this context, our study aimed to investigate patient safety attitudes amongst health care providers in Tunisian tertiary care hospital and help us to implement a process to improve care quality and patient safety.

Materials and Methods

Design and setting

We carried out a cross-sectional study during April May and June 2015 in Sahloul University hospital in Sousse: a 630-beds tertiary hospital in Eastern Tunisia. The number of admissions and the total number of hospitalization-days were respectively 28 079 and 199 497 in 2015.

Sample

All medical and paramedical staff that providing patient care and working in inpatient services of Sahloul hospital at least one month were included: senior physicians, assistant physicians, residents, nurses, technicians and nurse anesthetists. We exclude the caregivers and workers. Regarding physicians, we decided to collect information from all eligible and included physicians (n = 174). From 994 paramedical staff (669 nurses and 325 technicians), we proceeded by single elementary and random sampling to select participants. The sample size was determined based on a formula that allows for an expected prevalence of positive global perception of patient safety estimated at 23%, with the power of 0.8 at 95% confidence level. The required sample of paramedical personnel size was determined 283.

Survey instrument

We used the French version of HSOPSC for data collection [15]. HSOPSC has been tested on a large sample in United States, and has good supporting documentation [16-18]. HSOPSC has good psychometric criteria testing, including item analysis, exploratory factor analysis, confirmatory factor analysis, and inter-correlation and reliability analysis [16,17,19,20]. It also has been used and validated in different countries [20-24]. The French version of HSOPSC displays the perceptions of patient safety climate in 10 factors or dimensions (Table 1). The patient safety climate factors contain between three and six items each (a total of 40 items) and are all measured on a Likert scale, with a score from 1 to 5 on level of agreement: strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5).

Data collection

We distributed a paper-based questionnaire to the selected participants. They could freely and anonymously fill in the questionnaire and return their responses directly to the investigator.

Statistics analyze

Demographic data and the scores of patient safety culture dimensions were summarized using descriptive statistics. For each positively worded item, the percentage of positive responses was calculated–that is, the percentage of respondents answering the question by checking “strongly agree” and “agree” or “always” and “most of the time”. The scores of negatively worded items were reversed to ensure that higher scores always reflect more positive responses. Finally, a score was calculated for each dimension. It corresponds to the average proportions of positive responses per item. If the average was 75% or more, the dimension was developed. If it is between 50 % and 74%, the dimension needs to be improved. If it is under 50%, the dimension is non-developed. To compare the dimensions’ scores between physicians and paramedical personnel, the chi-square test was used, and p < 0.05 was recognized as statistically significant. All statistical analyses were carried out using SPSS Version 19 software.

Ethics

The study was approved by the ethics committee of Sahloul hospital. Verbal consent of the participants was obtained before administering the questionnaires.

Results

The overall HSOPSC response rate was 73.0% (344 out of 457 questionnaires) and, for each profession: physicians 63% (110/174) and nurses 82% (234/283). The mean age of participants was 37.2 ± 8.7 years. Of them, 47.7% were male and 52.3% female. While 197 (57.3%) of them were working in medical units and 147 (42.7%) were working in Surgical ones. Respondents reported having over than 10 years of experience at the hospital (31.1%). Table 2 lists the sample’s characteristics.

The percent of average positive responses (agree, strongly agree) varied between 43.3% and 59.4% across the ten patient safety dimensions of the HSOPSC (Figure 1). The highest percentage of positive responses was obtained from the “Frequency of events reported”, whereas items in the “Teamwork across units” dimension received the lowest percent of positive responses (Table 3). Areas with potential for improvement were “overall perception of security”, “Teamwork within units”, “Organizational learning/continuous improvement”, “Open communication and “Frequency of events reported”. There were no differences between physicians and nurses regarding all dimensions of the patient safety culture (Table 4).

Discussion

The measurement of safety culture and climate in healthcare is still in a relatively immature stage of development as compared to other domains (eg, offshore installations, manufacturing) [25,26]. Measuring of patient safety perception is the first step of a long process of cultural change and improvement of quality care. The safety culture environment is considered the most important barrier to improving patient care safety [27]. The starting point for developing a safety culture should be the evaluation of the current culture by using an appropriate instrument [21]. Few studies were conducted in Tunisian health facilities. One of them, our study is the first survey on patient safety culture among health professionals of Sahloul Hospital (Sousse, Tunisia).

Overall, we generally found low patient safety culture scores in our hospital. Our results suggested negative perception of the ten dimensions. No significant differences on patient safety culture perception levels between physicians and paramedical staff have been demonstrated. Similar results were reported in Iranian hospitals [28]. Whereas, the professions differed in their perception of patient safety climate in others studies [29-32]. This could be explained by the lack of effective communication and collaboration between physicians and other medical personnel, which has a profound effect on workplace environment and patient care [30]. Our results suggested that the same improvement strategies of patient safety culture are likely to have an impact for both physicians and paramedical staff. Our responses rate (73%) was higher than those reported in several other studies [21,32-34]. They varied from 37% to 63%. The undeveloped dimensions in our study were “Supervisor or manager expectations and actions promoting patient safety”, “Hospital management support for patient safety”, “Non-punitive response to error”, “Staffing” and Teamwork across hospital units which is a similar result as in other studies [20,35]. However, literature has shown different results and a wide variation between countries (Table 5). The differences regarding the perception of patient safety may be explained by the differences in organizational behaviour between cultural settings, organizational commitments, leadership, relationships within organizations and differences in methodologies, tools, populations and social culture. Despite the progress of patient safety assessment that has been made in recent years, there remains a significant patient safety issue that has yet to be formally recognized and systematically addressed, namely, the issue of culture and its possible links to patient safety [36].

The unit level dimension “Teamwork across hospital units” received a lowest percentage positive response in our study. Many safety culture measurement studies reported a negative perception regarding this dimension [14,28,29,33-35,37]. Whereas, it might be developed in Norwegian and Taiwanese hospitals [32,38]. Our respondents are not more likely to cooperate and coordinate with their co-workers. This situation does not allow the development of patient safety in our organization. Teamwork is an important part for the development of patient safety, and personnel should be encouraged and supported in their efforts to establish good relationships with people working in other units [39]. Thus, communication, handoffs and transitions are essential in the care process to ensure quality care. Communication within and across hospital units is critical in a healthcare environment as the patient is usually treated by several healthcare practitioners and specialists in multiple settings [40]. Evidence shows that communication problems are major contributors to adverse events [41]. Moreover, the number of events reported was significantly associated with the composites measuring communication openness, feedback and communication about errors, non-punitive response to error, hospital handoffs and transitions, and teamwork across hospital units [42]. On another hand, the respondents seem unsatisfied regarding Staff recruitment policy. The dimension “Staffing” had low percentage of positive responses, meaning that most of the respondents feel that staff allocation is not adequate to handle patient safety related workload.

Then, it is necessary to consider communication and teamwork as a priority to improve care safety and quality in our organization. We must act on two most implicated factors: workload and insufficient staff numbers [43]. They predispose to stress, anxiety and depression which increase the risk of occurrence of adverse events [44].

“Non punitive response to error” was the third undeveloped dimension in present study as reported by several studies [28,29,33-35,37,38]. Event reporting, an essential component for achieving a learning culture, can only happen in a non-punitive environment where events can be reported without people being blamed [21]. Many errors in health care go unreported for many reasons including fear, humiliation, the presence of a punitive response to error, and the fact that reporting will not usually result in actual change [45]. Paramedical staff cannot speak freely and believe that their mistakes are held against them and later kept in their files [46]. Promoting a blame-free climate is considered a key strategy for improving error-reporting frequency. Developing such a climate is associated with promotion of trust in the organization, and using systems approaches to error identification with focus shifted from individuals to processes [47]. The dimension “Non punitive response to error” showed strongest relationship with “Management Support for Patient Safety” and “Supervisor or manager expectations and actions promoting patient safety”, other undeveloped dimensions in our study. This could be partly explained by frustration of nursing staff regarding the loss of trust in hospital administration, listening, recognition of their clinical expertise and taking into account their views on patient safety. This loss of trust stems, in part, from a perception that initiatives in patient care and nursing work redesign have emphasized efficiency over patient safety [30]. Furthermore, management practices are essential to the creation of safety within the organization, and these practices include creating and sustaining trust throughout the organization [48].

In our organization, 56.9% of professionals perceived positively the need to take action to improve patient safety. This is the starting point for the promotion of safety culture. Thus, many recommendations could emerge to improve the quality and safety of care, taking into account our results: (i) Consider improving safety culture as priority, (ii) Place the patient at the centre of the concerns of public authorities, managers and health professionals (iii) Develop a non-punitive culture and encourage reporting of AEs, (iv) Team leaders must play their role as a “model” while promoting the culture of safety through consistent, both relational and organizational behaviours, (v) Promote teamwork and open communication, (vi) elaborate and simplify protocols and checklists and (vii) elaborate and execute a training program annually.

This present study has several limits. The quantitative assessment of patient safety culture using a self-administered questionnaire can be associated with a declaration bias. Indeed, self-administered questionnaire may influence the reaction of those who, for fear of reprisal or prosecution, will give social answers that do not reflect reality. However, this bias is more important in quantitative surveys based on interviews [49]. We used the French version of HSOPSC. This version may have measured different patient safety culture’s constructs in our sample from those meant by AHRQ [15]. The final structure of the tools does differ. This corroborates the need to adapt the tool to each country according to local ways of being, thinking, behaving and communicating [15]. Furthermore, HSOPSC does not calculate an overall score of patient safety culture. The validation of such score is complex and raises the problem of choosing the dimensions to be considered and their weightings. Finally, this study is carried out in a single hospital, which limits the external validity.

Conclusion

This study was an opportunity to familiarize health professionals with this concept of patient safety and to initiate a reflection on the current level of safety culture and its possible improvement. Our results suggest that the first step to patient safety improvement in our organization should be obtaining the support of hospital management, assuming a non-punitive approach to those who make and report medical errors and considering communication and teamwork.

  1. Aspden P, Corrigan J, Wolcott J, Patient Safety (2004) Achieving a New Standard for Care. Washington, DC: The National Academies Press. Link: https://goo.gl/GkUuDH
  2. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, et al. (1995) The quality in Australian health care study. Med J Aus 163: 458-471. Link: https://goo.gl/m74sQv
  3. Michel P, Quenon JL, Djihoud A, Tricaud-Vialle S, de Sarasqueta AM (2007) French national survey of inpatient adverse events prospectively assessed with ward staff. Qual Saf Health Care 16: 369-377. Link: https://goo.gl/Zd894S
  4. Hendrie J, Sammartino L, Silvapulle MJ, braitberg G (2007) Experience in adverse events detection in an emergency department: Incidence and outcome of events. Emerg Med Australas 19: 16-24. Link: https://goo.gl/Wjczf7
  5. Von Laue NC, Schwappach DL, Koeck CM (2003) The epidemiology of medical errors: a review of the literature. Wien Klin Wochenschr 30: 318-325. Link: https://goo.gl/uwtWf7
  6. Kohn LT, Corrigan JM, Donaldson MS (2000) To error is human. Washington DC: National Academy Press. Link: https://goo.gl/DLzoMs
  7. Weingart SN, Wilson RM, Gibberd RW (2000) Epidemiology of medical error. BMJ 320: 774–777. Link: https://goo.gl/re8RxQ
  8. WHO (2008) WHO Patient Safety Research. Geneva: World Health Organization. Link: https://goo.gl/qQ7GwA
  9. Nieva VF, Sorra J (2003) Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care 12: 17-23. Link: https://goo.gl/P6QeV4
  10. Smits M, Wagner C, Spreeuwenberg P (2009) Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital level. Qual Saf Health Care 18: 292–296. Link: https://goo.gl/YPYKi7
  11. Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004), AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality, 2004.
  12. Letaief M, El Mhamdi S, El-Asady R, Siddiqi S, Abdullatif A (2010) Adverse events in a Tunisian hospital: results of a retrospective cohort study. Int J Qual Health Care 22: 380-385. Link: https://goo.gl/paj2Xw
  13. Bouafia N, Bougmiza I, Bahri F, Letaief M, Astagneau P, et al. (2013) Magnitude and impact of serious adverse events related to treatment: study of incidence in a hospital in East Central Tunisia. Pan Afr Med J 16: 68. Link: https://goo.gl/zQvquv
  14. Bouafia N, Mahjoub M, Ben Cheikh A, Ezzi O, Jalleb  NB, et al. (2014) Mesure de la culture sécurité des soins auprès des médecins dans un hôpital tunisien. Santé Publique 26: 345-353. Link: https://goo.gl/ko8Ye3
  15. Occelli P, Quenon JL, Kret M, Domecq S, Delaperche F, et al. (2013) Validation of the French version of the Hospital Survey on Patient Safety Culture questionnaire. Int J Qual Health Care 25: 459–468. Link: https://goo.gl/737HNt
  16. Colla JB, Bracken AC, Kinney LM, Weeks WB (2005) Measuring patient safety climate: a review of surveys. Qual Saf Health Care 14: 364-366. Link: https://goo.gl/fCX356
  17. Fleming M (2005) Patient safety culture measurement and improvement: a how to guide. Healthc Q 8: 14-19. Link: https://goo.gl/BQCwLD
  18. Flin R, Burns C, Mearns K, S Yule, Robertson EM (2006) Measuring safety climate in health care: Developing and testing an instrument to measure hospital safety climate. Qual Saf Health Care 15: 109-115. Link: https://goo.gl/ie9ugD
  19. Flin R (2007) Measuring safety culture in healthcare: a case for accurate diagnosis. Saf Sci 45: 653-667. Link: https://goo.gl/gp92KE
  20. Hellings J, Schrooten W, Klazinga N, Vleugels A (2007) Challenging patient safety culture: survey results. Int J Health Care Qual Assur 20: 620-632. Link: https://goo.gl/5jRskc
  21. Smits M, Christiaans-Dingelhoff I, Wagner C, Wal GV, Groenewegen PP (2008) The psychometric properties of the ‘Hospital Survey on Patient Safety Culture’ in Dutch hospitals. BMC Health Serv Res 8: 230–239. Link: https://goo.gl/JB3DdX
  22. Waterson P, Griffiths P, Stride C, J Murphy, S Hignett (2010) Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. Qual Saf Health Care. Link: https://goo.gl/o4K5jD
  23. Pfeiffer Y, Manser T (2010) Development of the German version of the hospital survey on patient safety culture: dimensionality and psychometric properties. Saf Sci 48: 1452-1462. Link: https://goo.gl/J4SCnc
  24. Sarac C, Flin R, Mearns K, Jackson J (2011) Hospital survey on patient safety culture: psychometric analysis on a Scottish sample. BMJ Qual Saf 20: 842–848. Link: https://goo.gl/mM4FUD
  25. Mearns K, Flin R, Gordon R, Fleming M (1998) Measuring safety climate in offshore installations. Work Stress 12: 238-254. Link: https://goo.gl/Q6p3hS
  26. Zohar D (1980) Safety climate in industrial organizations: theoretical and applied implications. J Appl Psychol 65: 95-102. Link: https://goo.gl/ZkYP68
  27. Cooper JB (2003) Developing a culture of safety. Biomed Instrum Techn 37: 212-214. Link: https://goo.gl/KDCgbA
  28. Arabloo J, Rezapour A, Fard Azar FE, Mobasheri  Y (2012) Measuring Patient Safety Culture in Iran Using the Hospital Survey on Patient Safety Culture (HSOPSC): an Exploration of Survey Reliability and Validity. Int J Hosp Res 1: 15-28. Link: https://goo.gl/VzP9PU
  29. Bodur S, Filiz E (2010) Validity and reliability of Turkish version of "Hospital Survey on Patient Safety Culture" and perception of patient safety in public hospitals in Turkey. BMC Health Serv Res 10: 28. Link: https://goo.gl/drXAw1
  30. Abdelhai R, Ben Abdelaziz S, Ghanem NS (2012) Assessing Patient Safety Culture and Factors Affecting It among Health Care Providers at Cairo University Hospitals. J Am Sc 8: 277-285. Link: https://goo.gl/6e5WJq
  31. Abbas HA, Bassiuni NA, Baddar FM (2008) Perceptions of front-line healthcare provides towards patient safety: a preliminary study in a University hospital in Egypt. Top Adv Pract Nurs 8: 1-11. Link: https://goo.gl/rJ1reC
  32. Haugen AS, Softeland E, Eide GE, Nortvedt MW, Aase K, et al. (2010) Patient safety in surgical environments: cross-countries comparison of psychometric properties and results of the Norwegian version of the Hospital Survey on Patient Safety. BMC Health Serv Res 10: 279. Link: https://goo.gl/z2bubj
  33. El-Jardali F, Jaafar MH, Dimassi H, Jamal D, Hamdan R (2010) The current state of patient safety culture in Lebanese hospitals: a study at baseline, Int J Qual Health Care 22: 386-395. Link: https://goo.gl/J3xaQn
  34. Al-Ahmadi HA (2010) Assessment of patient safety culture in Saudi Arabian hospitals. Qual Saf Health Care 19: e17. Link: https://goo.gl/WRz3hP
  35. Robida A (2013) Perception of patient safety culture in Slovenian acute general hospitals. Int J Qual Health Care 25: 469-475. Link: https://goo.gl/i5A5MF
  36. Johnston MJ, Kanitsaki O (2006) Culture, language, and patient safety: making the link. Int J Qual Health Care 18: 383-388. Link: https://goo.gl/VvoVkd
  37. Rockville W, Sorra J, Famolaro T, et al. Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report. AHRQ Publication N°12-0017, 2012.
  38. Chen IC, Li HH (2010) Measuring patient safety culture in Taiwan using the Hospital Survey on Patient Safety Culture (HSOPSC). BMC Health Serv Res 10: 152. Link: https://goo.gl/T8ZDfT
  39. Singer SJ, Gaba DM, Geppert JJ, Sinaiko AD, Howard SK, et al. (2003) The culture of safety: results of an organization-wide survey in 15 California hospitals. Qual Saf Health Care 12: 112-118. Link: https://goo.gl/Uwr4T4
  40. World Health Organization (2007) Collaborating Centre for Patient Safety Solutions, Joint Commission International. Patient Safety Solutions. Geneva: WHO. Link: https://goo.gl/KAfQPd
  41. Beyer M, Rohe J, Nicklin PJ (2007) Communication and patient safety, In: Sanders J, Cook G. ABC of Patient Safety. Oxford: Blackwell 16 –19. Link: https://goo.gl/Mhxudh
  42. El-Jardali F, Dimassi H, Jamal D, Jaafar M, Hemadeh N (2011) Predictors and outcomes of patient safety culture in hospitals. BMC Health Serv Res 11: 45. Link: https://goo.gl/5nvyeo
  43. Baldwin DC, Daugherty SR, Tsai R, Michael SJ (2003) A national survey of residents’ self-reported work hours: thinking beyond specialty. Acad Med 78: 1154-1163. Link: https://goo.gl/LDTr5E
  44. Firth-Cozens J, Sandars J (2007) The nature of error. In: Sanders J, Cook G. ABC of Patient Safety. Oxford: Blackwell 4-8. Link: https://goo.gl/SD1Thd
  45. Van Geest JB, Cummins DS (2003) An educational need assessment for improving patient safety: results of a national study of physicians and nurses. National Patient Safety Foundation, White Paper Report 3. Link: https://goo.gl/ph3ZQo
  46. Wolf ZR, Hughes RG (2008) Error Reporting and Disclosure. In: Hughes RG. Source Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality (US) 336-379. Link: https://goo.gl/K5W9U8
  47. McFadden KL, Stock GN, Gowen CR (2006) Exploring strategies for reducing hospital errors. J Healthc Manag 51: 123-135. Link: https://goo.gl/YCLuQT
  48. United States Government Accountability Office (GAO) (2004) Veteran's Administration Patient Safety Program: A Cultural Perspective at Four Medical Facilities, Report number GAO-05-83 December 15. Link: https://goo.gl/qnZ3zR
  49. Szekendi MK, Barnard C, Creamer J, Noskin GA (2010) Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety. Joint Comm J Qual Patient Saf  36: 39. Link: https://goo.gl/t7NcFN
© 2017 Rejeb MB, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
 

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