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COMMENTARY Engaging consumers in safety and quality at Royal Adelaide hospital Leslye Long 1,2 , Alan Pearson 2,3 , Tamara Page 1 and Zoe Jordan 2,3 1 Royal Adelaide Hospital, Adelaide South Australia, Australia 2 The University of Adelaide, South Australia, Australia 3 Joanna Briggs Institute, Royal Adelaide Hospital, Adelaide, South Australia, Australia Abstract Objective The objective of this study was to elicit barriers and enablers of safe, high-quality care as identified by consumers, and to position consumers as ‘possessors’ of valuable knowledge related to systems and practices (as they had experienced these directly) rather than the receivers of knowledge and information. The central aim was to develop recommendations for consumer input into quality improvement, generated from the analysis of narrative accounts of their experiences. Methods The four-phase methodology adopted for this project involved the development of quality improvement strategies as identified (phase one) and validated (phase two) by consumers through the conduct of discovery interviews with 30 consumers over the age of 18 years who had experienced an adverse event. Clinicians and quality managers were then provided with an opportunity to validate the strategies identified through participation in a focus group (phase three). All data collected through discovery interviews and focus groups were transcribed and entered into the Joanna Briggs Institute Qualitative Assessment and Review Manager for analysis. The final phase of the study involved integrating this process of consumer involvement and of identified improvement strategies into the quality improvement program of Royal Adelaide Hospital. Results A total of 28 findings were entered into the Joanna Briggs Institute Qualitative Assessment and Review Manager for analysis. The process of meta-synthesis embodied in these programs involves the aggregation or synthesis of findings or conclusions. Six categories and four syntheses were derived through this process with key themes relating to assessment and prevention strategies, a necessity for improved education and communication, the hospital environment and the potential life impact that the experience of an adverse event may have. Conclusion Consumers identified a number of strategies that could contribute to improved safety and clinical outcomes in hospital and a reduction in adverse events. This current study provides a solid foundation upon which future research may be conducted. Key words: communication, consumer participation, safety and quality. Introduction The insights of consumers of health care on how systems and practices in health care can be changed to improve safety and quality could add to the growing knowledge in this area. Studies investigating adverse events have tradition- ally been principally undertaken from a medical perspec- tive. 1 There have been few attempts to explore the potential of capturing and analysing the experiences of consumers who have themselves experienced an adverse event, and using such data alongside other data sets to improve safety and quality. For the purpose of this study, there are several terms that require definition: 1 Adverse event – an unintended or unexpected injury or complication caused during a hospital stay. For the purpose of this study, adverse events have been limited to falls, pressure ulcers and other ‘minor’ events because of the difficulties in recruiting participants who had experi- enced anything more serious. 2 Consumer – an individual who has received medical attention, care or treatment. A consumer may also be a consumer advocate or representative; however, for the purpose of this study, it is restricted to those individuals Correspondence: Zoe Jordan, Joanna Briggs Institute, Royal Ade- laide Hospital, Adelaide, SA 5000, Australia. Email: zoe.jordan@ adelaide.edu.au doi:10.1111/j.1479-6988.2007.00099.x Int J Evid Based Healthc 2008; 6: 119–134 © 2008 The Authors Journal Compilation © Blackwell Publishing Asia Pty Ltd

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C O M M E N T A R Y

Engaging consumers in safety and quality atRoyal Adelaide hospital

Leslye Long1,2, Alan Pearson2,3, Tamara Page1 and Zoe Jordan2,3

1Royal Adelaide Hospital, Adelaide South Australia, Australia 2The University of Adelaide, South Australia, Australia 3Joanna BriggsInstitute, Royal Adelaide Hospital, Adelaide, South Australia, Australia

AbstractObjective The objective of this study was to elicit barriers and enablers of safe, high-quality care as identified byconsumers, and to position consumers as ‘possessors’ of valuable knowledge related to systems and practices (as theyhad experienced these directly) rather than the receivers of knowledge and information. The central aim was todevelop recommendations for consumer input into quality improvement, generated from the analysis of narrativeaccounts of their experiences.

Methods The four-phase methodology adopted for this project involved the development of quality improvementstrategies as identified (phase one) and validated (phase two) by consumers through the conduct of discoveryinterviews with 30 consumers over the age of 18 years who had experienced an adverse event. Clinicians and qualitymanagers were then provided with an opportunity to validate the strategies identified through participation in afocus group (phase three). All data collected through discovery interviews and focus groups were transcribed andentered into the Joanna Briggs Institute Qualitative Assessment and Review Manager for analysis. The final phase ofthe study involved integrating this process of consumer involvement and of identified improvement strategies intothe quality improvement program of Royal Adelaide Hospital.

Results A total of 28 findings were entered into the Joanna Briggs Institute Qualitative Assessment and ReviewManager for analysis. The process of meta-synthesis embodied in these programs involves the aggregation orsynthesis of findings or conclusions. Six categories and four syntheses were derived through this process with keythemes relating to assessment and prevention strategies, a necessity for improved education and communication,the hospital environment and the potential life impact that the experience of an adverse event may have.

Conclusion Consumers identified a number of strategies that could contribute to improved safety and clinicaloutcomes in hospital and a reduction in adverse events. This current study provides a solid foundation upon whichfuture research may be conducted.

Key words: communication, consumer participation, safety and quality.

Introduction

The insights of consumers of health care on how systemsand practices in health care can be changed to improvesafety and quality could add to the growing knowledge inthis area. Studies investigating adverse events have tradition-ally been principally undertaken from a medical perspec-tive.1 There have been few attempts to explore the potentialof capturing and analysing the experiences of consumerswho have themselves experienced an adverse event, and

using such data alongside other data sets to improve safetyand quality.

For the purpose of this study, there are several terms thatrequire definition:1 Adverse event – an unintended or unexpected injury or

complication caused during a hospital stay. For thepurpose of this study, adverse events have been limited tofalls, pressure ulcers and other ‘minor’ events because ofthe difficulties in recruiting participants who had experi-enced anything more serious.

2 Consumer – an individual who has received medicalattention, care or treatment. A consumer may also be aconsumer advocate or representative; however, for thepurpose of this study, it is restricted to those individuals

Correspondence: Zoe Jordan, Joanna Briggs Institute, Royal Ade-laide Hospital, Adelaide, SA 5000, Australia. Email: [email protected]

doi:10.1111/j.1479-6988.2007.00099.x Int J Evid Based Healthc 2008; 6: 119–134

© 2008 The AuthorsJournal Compilation © Blackwell Publishing Asia Pty Ltd

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directly receiving care as they had experienced theadverse event directly.These definitions have been derived from feedback

received from participants in this study.Improving safety and quality in healthcare systems is

complex, and there have been rapid developments nation-ally and internationally in the identification and evaluation ofstrategies to minimise adverse events and to improve report-ing systems involving all key stakeholders. Significant work isalso emerging on the contribution that consumer involve-ment can make to identifying and addressing practice andsystem structures and processes that compromise safety andquality.

Historically, the contribution of consumers relating toinvestigations of adverse events has been limited. An anno-tated literature review conducted for the Department ofHealth and Ageing regarding consumer complaints foundthat, while using complaints to improve safety and qualitywas generally perceived as a good idea, the approachtended to individualise grievances and minimise the impacton the organisation, its protocols and procedures.2 Thisstudy attempted not only to link intrinsically the responses ofparticipants with definitive recommendations for serviceimprovement, but also to ensure that recommendationscould be clearly correlated with an evidence-based approachto practice change.

Several studies have been identified that examined con-sumers experiences of adverse events.

A multistage, clustered survey using household interviewswas conducted, which sought to determine public opinionon the rate and severity of adverse events experienced inhospitals and the perception of safety in hospitals so thatpredictors of lack of safety could be identified.1 It was con-cluded that the experience of adverse events negativelyimpacted on public confidence in hospitals. The consumer-reported adverse event rates in hospitals (7.0%) are similarto that identified using medical record review. Based onestimates from other studies, self-reported claims of adverseevents in hospital by consumers appear credible, and shouldbe considered when developing appropriate treatmentregimes.

A survey focusing on health consumers’ experiences ofadverse events was conducted in 2001. The study describedthe incidence of adverse events, attitudes to participation inmedical decision-making and perceptions of safety.3

A 2002 survey was conducted on consumer health com-plaint experiences in order to encourage the establishmentof a Health Complaints Commissioner.4 The study found thatmost consumers who had an adverse event wanted changesin procedure to stop similar incidents and an apology. It wasconcluded that many systemic quality improvement oppor-tunities are being lost because consumers are hesitant aboutcomplaining.

A study was conducted in the USA to explore consumerperceptions of consumer–provider communication after anactual adverse medical event because prior consumer errorstudies are rarely based on real situations.5 The study con-ducted four consumer focus groups using a semistructured

guide, and transcripts were analysed using an editingapproach to identify themes. Provider communication time-liness and quality were important influences on consumers’responses to adverse events. Confronting an adversemedical event collaboratively helped both consumers andproviders address the consumers’ emotional, physical andfinancial trauma, and minimised the anger and frustrationcommonly experienced. Health organisations, providers,investigators and policy-makers should consider the con-sumer experience when developing provider training orevaluating processes in consumer resolution.

In the UK, the National Health Service ModernisationAgency reports on the utilisation of ‘consumer’ perspectivescollected through ‘discovery interviews’ to identify strategiesto improve the safety and quality of care provision.6 Theunderlying principle of discovery interviews is that the areaconsumers and carers understand best is the impact of theirillness or condition upon their lives. Discovery interviewsprovide an opportunity for consumers to directly tell thestory of their illness or condition using a framework (referredto as a ‘spine’) that guides them through the key stages oftheir experience.

In Australia, major national investment in consumerinvolvement has led to a range of approaches that empowerconsumers and publications, such as ‘10 Tips for Safer HealthCare’ produced by The Australian Council for Safety andQuality in Health Care, which aim at engaging consumers inpromoting safety and quality.7 Similarly, improvements inreporting systems are providing both health service provid-ers and consumers with information to monitor and improvesafety and quality.

However, the focus was generally around complaintsprocedures and issues surrounding blame, communicationfollowing an adverse event and consumers’ hesitationabout raising issues related to adverse events.

While these studies do address consumer perspectives onvarious elements of adverse events, they are limited in thatthey were predominantly survey designs, which limit theresponses received from those interviewed.

No attempt has previously been made to generate anopen dialogue with consumers to determine their experi-ence of an adverse event and potential strategies to preventadverse events from recurring.

The project sought to build on the current body of knowl-edge on safety and quality in the healthcare environment bycapturing narrative accounts of consumer’s experiences ofcompromised safety and quality and to evaluate the degreeto which this can contribute to quality improvement pro-cesses in a large tertiary teaching hospital. At the time thisresearch commenced, there had been a 2% increase inreported adverse events within the organisation in which thestudy was to be conducted. Of these, 516 had resulted in noharm, 188 had required some form of investigation or treat-ment and 10 had resulted in an increased length of stay andmorbidity. It was therefore deemed timely that such a studyshould be conducted to determine consumer perceptions ofadverse events and potential resolutions to prevent recur-rences of such events.

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Methodology

This project sought to elicit barriers and enablers of safe,high-quality care as identified by consumers, and positionedconsumers as ‘possessors’ of valuable knowledge related tosystems and practices (as they had experienced thesedirectly) rather than the receivers of knowledge and infor-mation. The central aim was to develop recommendationsfor consumer input into quality improvement, generatedfrom the analysis of narrative accounts of their experiences.

The project consisted of four phases:• Developing consumer-identified quality improvement

strategies• Consumer validation of identified strategies• Clinician and quality manager’s validation of identified

strategies• Quality improvement program

Phase 1: developing consumer-identified qualityimprovement strategiesSampleThe project sought to conduct discovery interviews with 30consumers who had experienced an adverse event in a largetertiary teaching hospital (such as a fall, the occurrence ofpressure-related ulcer, a hospital acquired infection or medi-cation error). This opportunistic sample was inclusive of bothmen and women who were over 18 years of age and whohad provided informed consent.

Data collectionData collection involved conducting in-depth discoveryinterviews with consumers who had experienced an adverseevent during their time in hospital. This approach followedthe approach developed by the Modernisation Agency.Within this context, discovery interviews are not conductedin the traditional interview style (i.e. questions and answers).Rather, the aim is to identify improvement strategies thatemerge from consumers’ stories.

An interview ‘spine’ was developed as a guide for thestories, and laminated cue cards included the words ‘admis-sion’, ‘being on the ward’, the specific ‘adverse event’(fall, pressure sore, medication error, infection), ‘gettingtreatment’, ‘getting better’ and ‘going home/life impact’.The same cards were shown to every consumer interviewedas a guide to them telling their story. The interviews wereconducted on the ward.

Data analysisThe interviews were audio-taped and transcribed, and thensubjected to thematic analysis using the Joanna Briggs Insti-tute Qualitative Assessment and Review Instrument (JBI-QARI) software program.

The steps involved in qualitative data extraction are basedon the processes embedded in the JBI-QARI softwarepackage. Data extraction involved transferring raw datafrom the interview using an approach agreed upon andstandardised for this specific project. An agreed format isessential to minimise error, provide an historical record of

decisions made about the data in terms of the project and tobecome the data set for extraction and synthesis. The formatfor data extraction involved the following steps:• Reading each interview carefully, then re-reading• Identifying and extracting key points (‘analysed data’)

within the interview• Entering the analysed data into the findings/conclusions

field in JBI-QARI• Locating the supporting raw data from the interview and

either transposing it verbatim or paraphrasing it as an‘illustration’

• Continuing this process for each interview until all keypoints from all the interviews have been entered intoJBI-QARI

Data synthesisData synthesis was performed using the JBI-QARI softwarepackage. The process of meta-synthesis embodied in JBI-QARI involves the aggregation or synthesis of the analyseddata.

The aim of the process is to generate a set of statementsthat represent aggregation through assembling the analyseddata rated according to their quality. Themes are then devel-oped from these data on the basis of similarity in meaning.

The themes are then subjected to a meta-synthesis inorder to produce a single comprehensive set of synthesisedfindings that can be used as a basis for evidence-basedpractice.

The JBI-QARI permits the reviewer to exercise some degreeof judgement. However, synthesis using JBI-QARI involvesboth an aggregation of identified themes and the use ofinterpretive techniques to summarise the findings of theindividual interviews into a product of practical value.

The features of content analysis that JBI-QARI draws oninclude the need to read and re-read the text to identify themeaning of the content, and the formation of statementsthat accurately describe the content. The features of dis-course analysis that JBI-QARI draws on are the steps pursuedto achieve confidence in the data being reviewed insofar asits purpose and its focus on serving the best interests ofhealthcare recipients.

Phase 2: consumer validation ofidentified strategiesIt was important that the results were deemed valid anduseful by participants in order to make a meaningful contri-bution to safety and quality throughout the hospital. Theresults of the analysis were posted to participants and to theConsumer Advisory Council of the Royal Adelaide Hospital.The Consumer Advisory Council provides advice and feed-back to the hospital on key aspects of the operation of thehospital and has undertaken significant work since its incep-tion in 2002 in an endeavour to ensure that consumers areinvolved in improving healthcare safety. Feedback was usedto ensure that only those results that were seen as valid byparticipants were included in the final results.

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Phase 3: clinician and quality manager’s validationof identified strategiesIt was also important to ensure that health professionalswere provided with an opportunity to validate the identifiedstrategies and ensure a truly collaborative approach to safetyand quality improvement. The consumer-validated resultswere therefore presented at a focus group consisting of sixquality managers and clinicians for discussion and feedback.This focus group was audio-taped, transcribed and subjectedto integrative analysis using the JBI-QARI software programusing the same processes and techniques as described forthe analysis and synthesis of the discovery interview data.This phase resulted in a report of synthesised results.

Phase 4: quality improvement programThe recommendations from phase 3 were presented to theSafety and Quality Unit, and discussion regarding strategiesto integrate them will be discussed and implemented wherepossible.

This phase of the project is an ongoing collaboration withthe Safety and Quality Unit, which will incorporate develop-ment of consumer information regarding safety and qualityrelating to specific interventions and conditions, and alsomore broadly in relation to general safety in the hospitalenvironment.

Royal Adelaide Hospital has already identified areas ofconcern, and they are working towards developing strate-gies for incorporating consumer experiences into theirquality improvement processes. This project has informedquality improvement from the perspective of the consumerand has promoted a collaborative approach to change. Theenhancement of the understanding of the consumer expe-rience with regard to adverse events in the healthcareenvironment has been most beneficial. The Royal AdelaideHospital fosters an environment that encompasses a cultureof safety, and is inclusive of all key stakeholders.

Results

Demographic informationNine men and six women were recruited between the agesof 20 and 88 years. Three consumers had developed pres-sure ulcers, seven consumers had experienced a fall, twoconsumers had developed a cannula abscess and three con-sumers had a combination of adverse events.

Discovery interview dataThe discovery interviews were transcribed and data enteredinto the JBI-QARI for analysis. The use of JBI-QARI for thisresearch was somewhat unconventional, as not all compo-nents of the program were utilised. Text that illustratedthemes, metaphors or concepts identified in the interviewswas entered into the findings component of JBI-QARI. Thesefindings were then assigned to categories and synthesised.

FindingsThe key findings of each interview and the illustration tosupport those findings are presented below.

Finding 1: Changes in strategy and process may help toprevent adverse events.

Illustration: Now what I do is take the bottle with me butbring another one back, so they fixed that up. [the con-sumer interviewed had identified the cause of his fall –that is, slipping on spilled liquid – and implemented achange to his own behaviour to prevent it from occurringagain]

Finding 2: Early discharge may contribute to the occur-rence of adverse events.

Illustration: Well, why did they let me go for that two orthree weeks when they knew something was wrongwith my foot? I should never have been let out of hereto start with and then it was my own doctor who toldme there were two bugs in there. And the district nursewho was coming around to change the dressing saw allthe green stuff in there, too. So I just don’t think any ofthem know what’s going on. Well, if they do they’re nottelling me too much.

Finding 3: Inappropriate use of equipment and insufficientassessment may lead to adverse events.

Illustration: From the shackles [form of restraint] I’d say.That’s what I reckon. The bottom was where my heelcouldn’t move, which is where the pressure sore camefrom. I can’t work out why they didn’t put some bandagearound or something so you don’t get hurt like that. Evenif they do come to shackles, there should be something tocover you. As it works now I came in here for oral surgeryand I could go out of here with one of my legs gone.

Finding 4: Individual consumer assessment is necessary toavoid adverse events.

Illustration: Oh, yes, yes, I did fall love. What are thosebottles you wee in? I was going down to the toilet (theywanted specimens) and I . . . tipped half the bottle of weeon the floor and of course slipped on it and bang, downI went.

Finding 5: Assessment to ensure adequate footwear mayassist in the prevention of falls.

Illustration: [regarding adequate footwear] No, no I hadthose things they put on me. Those stocking things.

Finding 6: Consumer concerns and observations may assistwith assessment and prevention.

Illustration: [daughter] It really concerned me especiallywhen I saw her walking around without any dressing onand when it didn’t burst I didn’t even think about septic,but I’m just so glad that it hadn’t burst [with the bugs onthe floor from high traffic].

Finding 7: Consumer observations can play an importantrole in assessment and prevention of adverse events.

Illustration: I did [notice the sores]. I knew they were downthere, but I can’t see them or anything.

Finding 8: Poor footwear may contribute to the occurrenceof a fall.

Illustration: [I was wearing] slippers, which is silly tooactually. Slippers are no good I don’t think inside onpavement floors.

Finding 9: Regular assessment and consumer observationwould assist in preventing adverse events.

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Illustration: They had been changing the bandages everyday and then yesterday I asked if they were going tochange them because they hadn’t been changed sinceFriday. When I use the word neglect I don’t point it at anyparticular person, I think it just comes down to not havingenough staff on the ward because there isn’t enough timein the day or in a shift to do everything that everyonewants.

Finding 10: Regular assessment for pressure ulcers is impor-tant to prevent adverse events.

Illustration: I mean, basically what happened is that I waslying in the bed and my feet were really hurting, but I’mnot a sook.

Finding 11: Regular assessment of the consumer and theircircumstances may prevent adverse events.

Illustration: I had finished my shower and the nurse puta towel on the floor and I wanted to clean my teeth,so I don’t know whether the frame got caught up inthe towel or my foot slipped on the towel. I’ve reallygot no idea what happened, but the towel was thecause of it.

Finding 12: Adverse events may occur when consumersfeel neglected.

Illustration: Work cover paid for it so I don’t own it, I justget to use it until I don’t need it or I pass away. So Ithink they thought, well he isn’t going to make it sowe’ll just give his wheelchair away.

Finding 13: Consumers knew they were doing the wrongthing, but felt it necessary to take actions regardless.

Illustration: I got off the bed because I had to go to thetoilet because the girl that was usually looking after mewasn’t here so I decided to get up myself, which wasn’tright and I knew it wasn’t right because I just couldn’twalk by myself.

Finding 14: Prognosis may affect care, which may result inthe occurrence of an adverse event.

Illustration: I think they developed in Intensive carebecause my first recollection when I came up here was thebandages and that was virtually from day dot comingback from intensive care. I think that’s pretty poor. A lot ofthe sisters on this ward have said to me that they neverexpected me to go home. They expected me to die herein hospital and I don’t know if that’s the attitude theytook from day dot. Well, what’s the use in turning him?What’s the use in taking him off his heels? And they justleft me lying on my back for days and days. And I thinkthat’s not very good.

Finding 15: When consumer complaints are ignored,adverse events may result.

Illustration: Oh, I knew it had gotten worse. It wasn’t thesame, but I kept telling the nurses and they wereignoring me . . . There was pain and a lot of pusscoming out of it. It was very unpleasant. I wanted themto get it out, but they didn’t do it straight away, I wassitting here nearly all morning, they just kept goingpast me.

Finding 16: When consumers feel neglected, adverseevents may occur.

Illustration: Yeah, I noticed it and I showed them but theydidn’t do anything about it until one nurse particularly,such a brilliant one, she saw it yesterday morning and wason to it like a flash.

Finding 17: Ensuring consumers have adequate informa-tion regarding safety is important to prevent adverseevents.

Illustration: Yeah, it was my sister I think and her fella, orher husband, were here and I got out of bed and I just, myfeet just fell out from underneath me, slipped out fromunderneath me. [The nurse] should’ve been here and Igot out of bed before she got here, that was all. They toldme to stay in bed until they could give me a hand. So it’smy blue, I suppose, not theirs.

Finding 18: Inadequate consumer information regardingsafety in hospital may lead to adverse events.

Illustration: Yeah [the fall] it was all my fault! That’s whatit was, it was all my fault. I was standing up and I wastrying to show off a trick . . . and it went wrong. I wastrying to stand up. Well, obviously I can stand up anyway,but um, my balance isn’t quite right. So that’s how ithappened.

Finding 19: Consumers require information and educationto be able to identify when an adverse event may occur.

Illustration: Yeah, I did [notice that it was red], but theyknow what the hell they’re doing.

Finding 20: Poor communication compromised carebecause different departments were working in contrastwith each other.

Illustration: It was only a couple of weeks ago somebloke came in here and told me they were taking meleg off on the Friday, then the next day another blokecame in and said don’t take any notice of him becausehe doesn’t know what he’s talking about, then I gotanother doctor come in and say neither of them knewwhat they were talking about . . . So I just stoppedeverything and said none of you are doing anythinguntil I work out what’s going on! Because they don’ttalk to each other and they all come up with differentstories. It’s bullshit!

Finding 21: When providing consumers with information,it is important to ensure that actions taken will not resultin an adverse event.

Illustration: When I was up in Intensive Care they kepttelling you to push your back up like that and my heel wasrubbing against one of those blankets and that’s how itstarted. That’s the only thing I can put it down to.Because the other leg, there’s nothing there, just thatone heel.

Finding 22: Overbalance when getting out of bed maycontribute to falls.

Illustration: I had a visitor and she was on that side of thebed and I got out the other and I was bending to put myslippers on and just fell over. As I said before there wasanother old lady who did the same thing and I washorrified. Then I went and did the same thing myself!I bent forward and just went straight forward. I just overbalanced.

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Finding 23: Poor orientation to surroundings contributedto the fall.

Illustration: The first three days, or the first four days . . . Ilost my way back to the ward eight times! Everythinglooks the same! It’s all white!

Finding 24: Unstable walking frames or furniture may con-tribute to falls.

Illustration: Then the other day I was here and I leant onone of those collapsible chairs [walking frame] and I putmy hand out to straighten the leg and I hit the groundand fell onto the muscle part of my thumb whichincreased to double the size and went a bluish navy blueif you can imagine that. In no time at all. The thumb didnot break.

Finding 25: An adverse event in hospital may impact on lifeat home.

Illustration: RDNS have been told so they can come and domy dressings. I’ve been doing my own bag for the lastweek, eight days and uh, RDNS will do my heels because Iwon’t be able to do them myself. I haven’t got theequipment at home to look after them and I can’t see themor know what they need, whether they need lubricating ordrying. Before I came in here I could get around, go to theshops or the post office . . . [now] I’ll give my carers a listand they’ll go.

Finding 26: The experience of an adverse event may resultin the necessity for ongoing care and impact on life athome.

Illustration: They [district nurse] used to ring before theycame. No specific time, they just used to ring and saywe’ll be there in 15 minutes.

Finding 27: The occurrence of an adverse event in hospitalmay result in treatment being required followingdischarge.

Illustration: I could hardly stand the pain. That was thenext day. And basically the result of this, I finished upwearing white stockings. It materialised here [in hospital]and now I have to wear stockings.

Finding 28: Adverse events such as falls may causeanxiety.

Illustration: . . . now I just have this fear of falling afterwhat happened. That was a rude awakening. Because Iwent into the bathroom yesterday morning and as soonas I saw that shower chair I had a panic attack. I thoughtI’m going to be sick, I’m going to pass out, I don’t knowwhat I want to do and I said to the nurse, I think I’mhaving a panic attack. But over what? Having a shower?No, it was the fall.

Categorisation and synthesis of findingsThe categorisation phase involves analysing findings andidentifying common themes. These common themes, orcategories, are further analysed to arrive at synthesised find-ings. A total of 28 findings were analysed, from which fourcategories were derived. These categories were furtheranalysed to produce five distinct syntheses. The information

below includes a description of the categories used tosupport the final synthesis of findings.

Synthesis 1 – assessment and preventionThe majority of responses were related to what was per-

ceived as a lack of adequate assessment. Eleven of the 28identified findings were related to assessment and preven-tion. Participants raised issues relating to the potential fortheir own assessment to contribute to a reduction in adverseevents (i.e. with regard to pressure ulcers or cannula siteinfections) providing that they were equipped with sufficientinformation to do so and that their concerns would beadequately addressed. Participants also felt that thoroughevaluation upon admission (including checking footwearand immediate surroundings) and prior to discharge wouldalso be beneficial. These comments resulted in the finalsynthesis ‘assessment and prevention’.

Synthesis 2 – education and communicationMany of the statements made by consumers regarding

their adverse event related to communication. Five findingswere categorised relating to a sense of neglect and five werecategorised relating to poor communication more generally.Whether this was in relation to communication between theconsumer and health professional or between health profes-sionals, there was consensus that poor communication con-tributed to the occurrence of adverse events. Consumers’comments indicated that with sufficient information regard-ing general safety principles in the hospital during their stay,strategies to prevent them from falling and education regard-ing the identification of signs of infection and strategies toprevent pressure ulcers, the incidents of adverse events maybe significantly reduced. These comments resulted in the finalsynthesis ‘education and communication’.

Synthesis 3 – hospital environmentSeveral consumers identified the hospital environment as

contributing to their adverse event. Three findings werecategorised in accordance with hospital environment. Thisincluded poor orientation to the ward and their surround-ings as well as inadequate and unsafe equipment such aswalking frames. It was considered that improving orienta-tion, ensuring that furniture is fixed and that objects arewithin reach could contribute to reducing the incidence ofadverse events. These comments resulted in the final syn-thesis ‘hospital environment’.

Synthesis 4 – life impactThe experience of an adverse event in hospital was iden-

tified as having a considerable life impact for consumers.Four findings were categorised relating to the experience oflife following an adverse event and one was related to thepsychological impact an adverse event may have. Adverseevents were attributed with affecting length of stay, psycho-logical factors relating to anxiety about the possibility ofanother event occurring and concern about managing theeffects of the event following discharge (in several cases,RDNS would be required to make visits following discharge).These comments resulted in the final synthesis ‘life impact’.

This is the QARI view displaying the syntheses for thereview: SIIP.

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Focus group dataThe focus group audio-tape was transcribed and dataentered into JBI-QARI for analysis. Text that illustratedthemes, metaphors or concepts identified throughout thefocus group was entered into the findings component ofJBI-QARI. These findings were then assigned to categoriesand synthesised.

FindingsThe key findings of the focus group and the illustration tosupport those findings are presented below.Finding 1: Footwear should be available for purchase by

consumers where appropriate.Illustration: I saw one consumer who had a really good

slipper with the Velcro over the top and so it was easy totake off but it was also firm fitting so if we maybe madesome of them available for purchase like the hip protec-tors down the front.

Finding 2: The hospital should not be responsible for foot-wear unless a recommendation has been made that com-promises consumer safety.

Illustration: I think we’re going to get ourselves caughtin something where we are supplying slippers to everysingle consumer that comes into the hospital if we makethat statement. I think if we put a consumer in TEDstockings, then we should ensure that they’ve gotappropriate footwear so they’re not walking around intheir TED stockings, but I don’t necessarily think thatwe should be providing the footwear for them unlesswe have made the recommendation that they wearstockings.

Finding 3: Continuous assessment is more effective thandischarge planning for preventing adverse events.

Illustration: Well, I guess you can identify [risk of pressureulcer] through your Braden score at the start. I mean,we’re continually assessing for pressure ulcers, so it’ssomething that should be regular anyway.

Finding 4: It is important to assess for risk and take action.Illustration: If you identify a risk and act to ensure that that

risk is reduced, then that still covers all of those things[falls, pressure ulcers, infection].

Finding 5: Processes are already in place to deal with risk offalling.

Illustration: I think to an extent there are things in placealready with the falls risk assessment. It is just whether thestaff carry them out.

Finding 6: Risk assessment may prevent someone frombeing discharged with a pressure ulcer.

Illustration: It’s your Braden score and your continualassessment of your Braden that is going to preventsomeone from being discharged with a pressure area thatdevelops very quickly into a pressure sore. I mean, if they[consumers] are at high risk and are being assessed regu-larly it is definitely something we should be doing andlooking at.

Finding 7: Placement of equipment for the prevention offalls is controversial.

Illustration: The other thing to consider is that it would begreat to be able to leave the consumers walking frameright next to their bed, but if we do then we are going totrip over it when we go to give the consumer their tabletsor whatever. Yes, if they were at home they would be able

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to have it close by, but in hospital there are other peoplethat need to be able to get to them.

Finding 8: Placement of equipment may also be an occu-pational health and safety issue.

Illustration: Most of them [consumers] will just get up andshuffle over to it anyway. The statement is fine, but wehave to have some level of oc health and safety for thepeople who are trying to move in and around those areasas well and that’s not just the staff, but the consumersvisitors as well.

Finding 9: Audit of non-slip floors should be made apriority.

Illustration: So maybe we should be auditing the non-slipfloors and then making a recommendation that we don’tuse towels.

Finding 10: Education may be necessary in order toencourage cultural change.

Illustration: Because I think that’s a cultural thing withnurses as well, putting towels on the floors.

Finding 11: Towels should not be placed on the floors toprevent slipping.

Illustration: No, I agree, I don’t think we should beputting towels on the floor. We have non-slip floors inall of our bathrooms. Drying the floor and getting rid ofthe towel to me is an option, but not leaving the towelon the floor.

Finding 12: Signage should be incorporated into floor tilesbecause that is where consumers tend to look.

Illustration: Maybe we could put something in the tiles onthe floor. Yeah, I like that idea. Have we actually repairedthat yellow line that goes around? Because I have seenpeople who are so focused on that yellow line that theyare walking on top of it.

Finding 13: Signage should be appropriate to/considerateof consumer behaviour.

Illustration: That’s one of the big things that the Austra-lian Army teach people out in the field is to look upbecause the man in the tree is going to shoot you asquickly as the man on the ground and no one looks up.It takes quite a long time to get used to, that when youare walking around you look up. So if the army hastrouble with that, then trying to teach consumers tolook upwards in an environment, which is so totally dif-ferent to the one they are normally in, is exactly thesame.

Finding 14: Consumer awareness should be raised regard-ing adverse events and safe behaviour in hospital.

Illustration: [development of a ‘be safe in hospital’ pam-phlet for consumers] It’s a good idea.

Finding 15: Evidence-based consumer information pam-phlets should be made available to consumers whereavailable.

Illustration: I think it is great that they are being devel-oped, it just concerns me that if we had to give them toevery single consumer they wouldn’t be as effective. It ismore a matter of that information being made readilyavailable and that the consumer is aware of it and canaccess/request it.

Finding 16: Consumer information should also be madeavailable to staff.

Illustration: It would probably also be good to make themavailable to staff development for when they teach nurseshow to insert IV’s so that they are made aware of thepamphlet.

Finding 17: Consumers should always be kept informed,but that is not always feasible.

Illustration: I wish we could do that [keep consumersinformed] all the time, but if a consumer was cared forin ICU and something happens, then they come downto us, it is still a concern for them because it is theirexperience, but we’ve all moved on because so manyother things have happened to the consumer since. I’dlove to see that happen all the time. I just don’t thinkthat it is realistic.

Finding 18: Consumers should be involved in all aspects oftheir care, but consumer information sheets should bekept to a limit.

Illustration: I think we need to be involving consumers inall levels of their care and I think that involving them intheir care and in decisions about their care is important.Now I love consumer information sheets, but we have somany of them and if you gave a consumer informationsheets to a consumer on every single thing, they’re notgoing to read them all. So I really think those should bekept for the “big-ticket” items.

Finding 19: There should be a process to ensure thatconsumers are informed and do not feel anxious aboutanother adverse event occurring.

Illustration: There is actually room on the AIMS form to saywhether they [consumers] are aware of this. And that israrely used. Has the consumer been notified, has the nextof kin been notified, has the doctor been notified, has itbeen documented in the case notes and very rarely wouldany of them get ticked. So maybe we need to go back andreview the AIMS process to ensure that we actually usethat check list.

Finding 20: Appropriate and thorough handover of careshould be established.

Illustration: Maybe there just needs to be better hand overof care between departments. I know that can be an issuewith us sometimes.

Finding 21: Communication between medical specialitiesis a concern.

Illustration: Is it just common between medical specialitiesor is it across the board? Because I would have thoughtthat nurses and physios and OT’s would work fairlywell together . . . they tend to care plan very welltogether.

Categorisation and synthesis of findingsA total of 21 findings were analysed to produce seven cat-egories. These categories were further analysed to producethree distinct syntheses. The information below includes adescription of the categories used to support the final syn-thesis of findings.

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Synthesis 1 – appropriate footwearThere was considerable discussion within the focus group

regarding the issue of appropriate footwear. Two findingsrelating to the availability of footwear and the responsibilityof provision of footwear were categorised. These commentsresulted in the final synthesis ‘appropriate footwear’.

Synthesis 2 – audit and assessmentEleven findings were categorised relating to various

aspects of audit and assessment of processes and equip-ment. These related to continuous assessment and pre-vention strategies for adverse events, assessment ofoccupational health and safety issues, and regular audit andassessment of signage and wet areas throughout the hospi-tal. These comments resulted in the final synthesis ‘audit andassessment’.

Synthesis 3 – communicationAs with consumers who participated in this study, com-

munication was deemed to be of significant importance tohealth professionals. Eight findings were categorised fromthe focus group discussion relating to communication.These related to the production and dissemination ofevidence-based health information pamphlets for consum-ers, consumer involvement in care planning and implemen-tation and strategies for improved communication betweenhealth professionals. These comments resulted in the finalsynthesis ‘communication’.

This is the QARI view displaying the syntheses for thereview: SIIP focus group.

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Discussion

The perspectives, experiences and expectations of consum-ers of health care have increasing potential to contribute tosafety and quality initiatives and improving service delivery.Investigations of adverse events usually focus on the actionstaken by individuals leading to the occurrence of an adverseevent and seldom focus on the perspectives of consumers.

The individual experiences of consumers who had experi-enced an adverse event identified not only to barriers andenablers of safe, high-quality health care, but also to thepotential contribution that consumers may make towardsthe utilisation of the best available evidence in the clinicalenvironment.

Consumers showed considerable concern regarding con-sumer assessment in the prevention of adverse events.Responses indicated that care might have been compro-mised when assessment was not thorough and consistent,and it was recognised that there was a lack of consumerinvolvement in this process. It may be that consumers havethe potential to play an important role in assessment andprevention strategies providing that they are adequatelyinformed of processes and indications for adverse eventsspecific to their condition or situation. If consumers and theirfamilies or carers are recognised as active participants in theircare and in assessment and prevention strategies, it may bepossible to reduce the incidence of adverse events. Involvingconsumers as valued partners on the consumer care team,and providing them with essential information about theircare were identified as key elements in the preventionprocess.

Language, personality and perception all impact on suc-cessful communication and the ability of health professionals

to communicate effectively with consumers in their care andin turn with the potential for an adverse event. A lack ofadequate information provision was identified as being a keycomponent driving the failure of both consumers and otherhealth professionals in the prevention of adverse events. Thenecessity for consumers to have information regardingboth general safety within the hospital environment andcondition-specific information relating to signs of trauma orinfection was deemed to be of significant importance.Assumptions and perceptions of the consumer/health pro-fessional relationship and the roles and responsibilities ofeach often contributed to the occurrence of an adverseevent. Consumers must have a clear understanding of theirresponsibility and right to raise their concerns regardingtheir condition, and health professionals must have a clearunderstanding of the contribution that consumers maymake to their care and in the prevention of adverse events.

A hospital cannot be an effective place of healing unless itis first ensured that the physical environment is safe. Forconsumers, orientation to their physical surroundings andwhat is considered to be safe and unsafe behaviour withinthat environment is critical. Potential environmental issuesidentified by participants of this study included adequatesignage on doors, orientation to the ward and the hospital,ensuring that furniture is stable and that objects such aswalking frames are within reach. Policies and practicesshould be in place to ensure that the hospital environment issafe and that consumers and staff behave in a safe andappropriate manner for the duration of their stay.

Clearly, the condition with which a consumer suffers mayresult in the requirement of assistance following discharge.However, in several of the cases included in this study, theadverse event experienced by the consumer also influenced

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life following discharge. The potential life impact for oneparticipant was significant with the adverse event resultingin the possibility of losing a leg as a result of early dischargeand an inadequately evaluated pressure area. While thissynthesis does not point to specific recommendations forclinical practice change (other than the need to rigorouslyapproach strategies for the prevention of adverse events), itis important to remember that these events can impacton the life of a consumer long after their discharge fromhospital.

It is interesting to note that many of the causes for adverseevents identified by consumers in this study are congruentwith the extant literature. For example, causes of falls wereidentified as including when moving from one place toanother (usually the bathroom), getting out of bed andinappropriate footwear.

The syntheses derived from the results of the focus groupdiscussion with health professionals proved invaluable andcomplemented the consumer perspectives. Much of the dis-cussion surrounding safety and quality issues raised by con-sumers resulted in the development of practical solutions.Similarly, education and communication and assessmentand prevention are often cited in the literature as contribut-ing to adverse events.

Participants recognised that there was often cause forconsumers to be unable to wear appropriate footwear, or infact anything at all on their feet, but concerns were raisedregarding the level of responsibility the hospital should takewith regard to the supply of appropriate footwear to con-sumers. It was deemed inappropriate for the hospital toprovide adequate footwear to every consumer, but it wasthought that it would be reasonable and feasible to haveappropriate footwear available to consumers for purchaseand for the hospital to provide (where necessary) footwearonly when there had been a recommendation for care madethat compromised consumer safety (such as the wearing ofTED stockings).

Participants identified regular audit and assessment of allpotential risk areas, whether related to continuous assess-ment of consumers, procedures or equipment, as critical tothe prevention of adverse events. Continuous assessmentof individual consumers using the Braden Scale for Predict-ing Pressure Sore Risk or falls risk assessment tools wereconsidered to be a vital and necessary component of careplanning for every consumer. However, concern was raisedwith regard to whether such tools were utilised on aregular basis as part of the core activities of each healthprofessional.

Regular audit and assessment of the hospital environ-ment and procedures was also raised as a point of concern.Participants felt that with the introduction of non-slip floor-ing to most ‘wet areas’ in the hospital, the use of towels toprevent slipping was inappropriate. While it was felt thatusing towels to dry the floor was acceptable, it was sug-gested that the towel should be removed immediatelyafter use and not left on the floor. It was also suggestedthat regular audit and assessment should also be con-ducted regarding signage throughout the hospital and

recommendations made to the re-development team, par-ticularly with regard to ward orientation. A suggestion wasmade to include ‘directional’ signs within the tiles on thefloor as this tended to be where the consumer would focustheir attention (particularly those consumers with poormobility).

Placement of equipment, such as walking frames andchairs, was controversial. Participants were cognisant of thefact that consumers would require furniture and equipmentto be within reach. However, they were also mindful thatclinicians would also require access to the bedside for care,making placement of furniture and other equipment apotential occupational health and safety risk. It was sug-gested that this would need regular assessment on an indi-vidual consumer basis.

Participants identified communication as being equallychallenging as it is beneficial. It was agreed unanimouslythat consumer education regarding safe practices in thehospital was fundamental to consumer safety, and that infor-mation regarding safety issues should be distributed uponadmission to hospital. The provision of evidence-basedhealth information was discussed, and there were somereservations regarding information overload and the poten-tial that may have on the effectiveness of such information.However, it was thought that such information would proveuseful and could be made readily available to consumersupon request.

Participants recognised the necessity for consumers to beactively involved in their care and in decisions regardingtheir care, but this was not thought to be without theexistence of barriers. Care is often the responsibility of morethan one department or clinical area, and involves a signifi-cant number of different health professionals. It was agreedthat communication should occur frequently and thor-oughly regarding adverse events. However, this was notconsidered to always be feasible when the incident occurredand care was received in another ward or area. It wassuggested that thorough handover of consumers and com-munication between medical specialties could be betterfacilitated.

As discussed in the extant literature, it is clear that con-sumer perspectives on adverse events have significantpotential to inform service improvement strategies. Whilethe outcomes of the current study were in line with previouswork, the open dialogue generated here enable consumerperspectives to be obtained without limiting them in anyway. It is felt that this study further strengthens the body ofknowledge relating to consumer perspectives on safety andquality improvement strategies.

While these syntheses identified areas where it was feltthat service improvements could be made, it is also impor-tant to note that much was learned from the discoveryinterviews that confirmed and valued high-quality currentpractice. It is important that these aspects are acknowledgedand celebrated. Because of the nature of this project, thesecomponents of the interviews were not the focus of thesyntheses; however, this information was fed back to clini-cians at a safety and quality forum.

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LimitationsThe limitations of this investigation were related to recruit-ment of participants and terminology. The process of recruit-ing participants for this research was controversial. It wasoriginally intended that participants would be recruited viathe Advanced Incident Management System (AIMS) forms.AIMS is a computerised system for collecting, classifying,analysing, managing and learning about things that gowrong in health care, which allows the collection of infor-mation from a wide variety of sources and enables thatinformation relating to incidents may be classified in a con-sistent way, so that subsequent, detailed analysis is possible.However, upon submitting the proposal to ethics, it wasdiscovered that AIMS is a declared quality-assurance activityunder the Health Insurance Act 1973: Part VC, HealthInsurance Amendment Act 1992. This legislation providesstatutory protection of identified data (e.g. nurse/doctor/consumer’s names) collected solely for the purpose of theAIMS process. Passing on the AIMS form, or disclosing iden-tified information contained within a form, to people whoare not involved in the AIMS process is considered to be abreach of the Act.

Following a meeting with the Department of Health, itwas decided that participants would be recruited via the staffin the hospital. This process also presented difficulties withstaff hesitant to contact the research team, feeling that theymay be putting themselves or the hospital at risk of litiga-tion. The aims of the project were presented at a NursingForum in the hope that this would reassure staff and encour-age them to recruit participants. Unfortunately, nursing staffare busy and the demands on them for research projectsabundant. The most effective strategy for recruitment wasdoing ward rounds to ask staff if there had been an adverseevent.

Terminology also proved difficult, with participants requir-ing considerable explanation as to what was meant by an‘adverse’ event. Following an interview where a participantdescribed the event as ‘unexpected’, this term was adoptedfor the duration of the research. It is important to note thatwhen conducting research with consumers of health care,language can make an enormous difference to the responsesgiven. Using plain English language that is free of jargon iscritical in such circumstances.

Conclusions

This project demonstrated the potential of consumers tocontribute to meaningful outcomes regarding the preven-tion of adverse events in hospitals. Involving both serviceusers and service providers in the process of identifyingsafety and quality issues in clinical practice can strengthenthe relevance of the changes being made and assist inestablishing priorities for service improvement. Consumersinvolved in this study identified poor communication, insuf-ficient consumer education, poor assessment and preven-tion strategies and the clinical environment as contributingto the occurrence of adverse events. The identified concernsresulted in poor consumer outcomes, some of which were

significant impacting not only on their hospital stay but theirlife after hospital also. The health professionals involved inthe study concurred with consumers regarding the identifiedcontributing factors and offered some constructive feedbackwith regard to how such issues may be overcome by facili-tating immediate practice change and making recommen-dations for the future.

Recommendations for practiceThe following recommendations are based on the feedbackreceived by both consumers and health professionals andare made with a view to improving consumer care andreducing the incidence of adverse events in hospital:

Assessment and prevention1 Risk should be assessed for all aspects of care and action

taken as determined on an individual basis.• Towels may be used to dry wet floor, but should not

remain on the floor where they may cause a fall• Consumers who are required to collect urine specimens

should not carry the specimen back, but inform staff sothey may retrieve it

• A multidisciplinary approach should always be takenregarding pressure ulcers when repositioning consum-ers or where exercises are recommended for in-bedstrategies must be utilised to reduce shearing

2 Footwear should be assessed upon admission to the wardand appropriate footwear made available for purchasewhere possible (if wearing stockings, socks or slipperswith insufficient grip) to minimise the incidence of falls.

3 Adequate decision support systems should be put in placethat acknowledge the contribution that consumers canmake to the prevention of adverse events.

Education and communication1 Where possible/feasible following an adverse event, con-

sumers should be adequately informed of what occurredand the processes followed (i.e. if the consumer wasunconscious when event occurred).

2 Evidence-based consumer information pamphlets thatcomplement best practice information received by staffshould be made available to consumers and they shouldbe encouraged to participate in their care and in theprevention of adverse events.

3 Health professionals should be aware that consumers mayfeel anxious following an adverse event and should reas-sure them.

4 Consumer awareness should be raised regarding risk ofadverse events and safe behaviour and practices in hos-pital (i.e. provision of a ‘be safe in hospital’ pamphlet intheir admission pack).

5 When more than one department or clinical area isinvolved in the care of an individual consumer, thereshould be adequate communication of care plans toensure continuity of care and a holistic approach to care.

Hospital environment1 Equipment should be placed within the reach of consum-

ers or completely out of sight so that they must call for

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assistance in order to reduce their risk of falling. Thisshould be assessed on an individual basis and the occu-pational health and safety of staff considered as well asthe safety of the consumer and their visitors.

2 Regular audit and assessment (i.e. for wet areas andsignage) should be conducted on a regular basis in orderto reduce the incidence of adverse events.• Wet areas should be assessed to ensure they have non-

slip floors (towels should not remain on floors afterdrying)

• Consumer requirements regarding signage should beassessed and placement of ‘directional’ signs in floortiling should be considered (e.g. indicating bays andbed numbers)

Recommendations for further researchIt is important to note that, while the focus of discoveryinterviews is not on the number of interviews conducted buton the quality and number of improvements that may beimplemented, the results of this study are by no meansconclusive, and the numbers of participants recruited werenot sufficient to achieve saturation. They do, however,

provide a pivotal foundation upon which further investiga-tion may be based.

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