1. January-February 2016 • Vol. 25/No. 1 17
CPT (R) Gwendolyn Godlock, MS-PSL, BSN, RN, AN, CPHQ,
is Field Representative Nurse
Surveyor, The Joint Commission, Oakbrook, Terrace, IL.
CPT Mollie Christiansen, BSN, RN, AN, CMSRN, is Clinical
Nurse Officer in Charge, Burn
Progressive Care Unit, United States Army Institute of Surgical
Research, Joint Base San
Antonio Fort Sam Houston, TX.
COL Laura Feider, PhD, RN, is Dean, School of Nursing
Science and Chief, Department of
Nursing Science, Army Medical Department Center and School,
Health Readiness Center of
Excellence, Joint Base San Antonio Fort Sam Houston, TX.
Acknowledgments: The team would like to thank nursing
leaders COL (R) Sheri Howell, for-
mer Deputy Commander of Nursing and Chief of Staff; and
COL Richard Evans, Assistant
Deputy Chief Army Nurse Corps, for their support. A special
acknowledgment for the former
Chief, Medical Nursing Section, COL Vivian Harris, who
remained a staunch supporter, advo-
cate, and cheerleader, the Medical Section nursing staff, and the
Center for Nursing Science
and Clinical Inquiry.
Note: The view(s) expressed herein are those of the authors and
do not reflect the official policy
or position of Brooke Army Medical Center, the U.S. Army
Medical Department, the U.S. Army
Office of the Surgeon General, the Department of the Army,
Department of Defense, or the U.S.

2. Government.
Implementation of an Evidence-Based
Patient Safety Team to Prevent Falls
in Inpatient Medical Units
T
he Centers for Medicare &
Medicaid Services identified
falls as a preventable health
care acquired condition (DuPree,
Fritz-Campiz, & Musheno, 2014). A
large portion of the medical-surgical
inpatient population is aging, and
therefore at high risk for falls (Boltz,
Capezuti, Wagner, Rosen berg, &
Secic, 2013). Falls have physical and
emotional implications for patients,
as well as increased financial costs for
facilities. Nationally, medical units
have the highest rates of falls
(Bouldin et al., 2013). Most notably,
falls can cause significant injuries
resulting in increased length of stay,
unexpected surgeries, and even death
(Williams, Szekendi, & Thomas,
2014). Historically medical-surgical
nurses care for a mix of complex
patients with an array of comorbidi-
ties and patient needs (Carter &
Burnette, 2011).
Literature Review
The literature search was limited

3. to keyword searches on falls, team-
work, patient safety, nursing, hourly
rounding, and communication. Data -
bases included PubMed, EBSCO,
Agency for Healthcare Research and
Quality, CINAHL, and The Joint
Commission for years 2008-2014.
Use of fall prevention teams was an
emerging evidence-based practice
(EBP) intervention to decrease the
incidence of inpatient falls (Graham,
2012). Consistently, the evidence
demonstrated ineffective communi-
cation, situation awareness, team-
work, assessment, hourly rounding,
and environmental challenges as key
factors related to preventable inpa-
tient falls.
Collectively, researchers have
shown improving teamwork through
successful integration of standard
EBP tools proved most efficient in
reducing preventable inpatient falls.
Successful falls prevention strategies
included staff education about the
fall-injury risk assessment tool, post-
fall assessments, alarm device usage,
side effects of medications, hourly
rounding, and offering toileting fre-
quently (Tzeng & Yin, 2012). Re -
search also suggested hourly round-
ing positively impacts patient fall

4. rates, call bell usage, and patient
satisfaction (Olrich, Kalman, & Nig -
olian, 2012).
The focus of the literature review
was to identify strategies for improv-
ing collaborative care, with empha-
sis on teamwork at the microsystem
level. Engaging clinical nurses is key
in the creation of an effective falls
prevention team. Teams include
champions on each nursing unit.
Unit champions are responsible for
educating staff on all incident
trends and the latest preventions
strategies (Graham, 2012).
This project examined the use of
Continuous Quality ImprovementContinuous Quality
Improvement
Gwendolyn Godlock
Mollie Christiansen
Laura Feider
Falls are a patient safety priority among hospital inpatients. The
creation of a Patient Safety Team engaged frontline staff in
patient
safety and falls prevention. This intervention decreased the fall
rate
from 1.90 to 0.69 falls per 1,000 occupied bed days.

5. January-February 2016 • Vol. 25/No. 118
EBP TeamSTEPPS® to enhance com-
munication and teamwork. Prior to
this EBP project, clinical nursing
staff were not aware of environmen-
tal risk factors contributing to inpa-
tient falls. Patient education regard-
ing fall risks varied across the depart-
ment and preventive strategies were
not standardized. EBP TeamSTEPPS
provided clinical nursing staff with a
simple, yet structured approach to
identify fall risk factors and apply
patient-specific interventions. Most
notably, this project emphasized
shared accountability and adher-
ence to a standardized process. This
was a departmental approach be -
cause inpatient falls were considered
the nurse executive’s patient safety
priority.
Methodology
Throughout the first half of
2013, medical nursing section lead-
ers noted an increase in inpatient
falls. The section chief tasked a clin-
ical nurse to work with the nursing
services patient safety officer to
address this emerging problem.
Based on their outstanding clinical
skills, nursing judgment, and com-
mitment to patient safety, section
chiefs nominated fall team mem-

6. bers. All nominees agreed to partic-
ipate in the group. Because all train-
ing, education, and interventions
were completed during the nurses’
working day, no additional funding
was required to start the group. Staff
in the Department of Hospital
Education Simulation Center partic-
ipated with strong support from
hospital leaders.
Continuous quality improve-
ment guided this EBP project specif-
ically using the FOCUS-PDCA
model (Shugdar, n.d.). This model is
commonly used in health care as a
systematic method to analyze and
improve processes (Peer & Rakich,
2000). FOCUS-PDCA has been used
throughout the project facility for
process improvement. The team
discussed various components of
the project using the FOCUS-PDCA
model. Leaders are responsible for
managing quality improvement
projects by maintaining open dia-
logue with clinical staff.
FOCUS-PDCA methodology con-
sists of nine-steps:
• Find a process to improve.
• Organize a team.
•� Clarify current process.
•� Understand variations in cur-

7. rent process.
•� Select process improvement.
•� Plan the improvement.
•� Do the improvement.
•� Check for results.
•� Act to hold the gain (Peer &
Rakich, 2000, pp. 188-193)
To align with the Partnership for
Patient Outcome measure, the pri-
mary quality indicator used for this
project was inpatient falls per 1,000
bed days. These numbers were calcu-
lated using patient safety reporting
(PSR) and the Workload Manage -
ment System for Nursing.
The pre-intervention average fall
rate for the medical nursing section
was 1.90 falls per 1,000 bed days.
All inpatient actual and near-miss
falls were reported by nursing staff
through the PSR system, and the
fall rate was calculated at the end of
every month by project leaders.
The main components during the
implementation phase of the
Patient Safety Team included a
Patient Safety Stand-down Week,
identifying Safety Team Cham -
pions, Patient Safety Journal Club,
completion of the Perfect Storm
Falls Simulation training, and
trending fall incident rates before
and after implementation.

8. During the Medical Nursing
Section Patient Safety Stand-down
Week, the Fall Safety Team evi-
dence-based project was launched.
Over a 1-month period, all team
members of the medical section
(N=6 inpatient nursing units)
received safety-specific training
with a focus on fall prevention,
team goals, and purpose. Licensed
nursing personnel received training
on critical thinking in falls preven-
tion and all team members received
training on bed mechanics (bed
alarms, side rails, locks, etc.).
Classes were offered over 5 days
during day and night shifts, to
achieve a goal of 85% trained.
Formation of Fall Safety
Team
The medical section Fall Safety
Team included registered nurses
(RNs), licensed vocational nurses
(LVNs), and certified nursing assis-
tants (CNAs), and included identi-
fied champions from each shift of
the medical inpatient units. Unit
champions were identified, trained
on fall preventions and interven-
tions, and used as instructors dur-
ing the Patient Safety Stand-down
Week. An on-duty, on-call roster
was created each month using the

9. current work schedule so one team
member was on-call around the
clock to respond after a patient fall.
This roster was posted in the charge
nurse room on each unit. If a fall
occurred, the Fall Safety Team
member went to the location of the
fall as soon as possible, completed a
post-fall checklist (see Figures 1a-
1b), and facilitated a safety huddle
with the nursing staff, patient, and
family. During this safety huddle,
evidence-based interventions were
discussed and recommendations
made to continue to keep the
patient safe. Additionally, unit staff
were alerted to potential causes for
the fall and encouraged to check
the safety of all other patients on
the unit. Nursing vigilance was seen
as paramount if increased falls were
noted across a section.
At monthly meetings, represen-
tatives brought all post-fall check-
lists so team members could discuss
recent falls throughout the section.
The team made recommendations
to nurse leaders for process im -
provement and targeted evidence-
based interventions. Unit champi-
ons were responsible for educating
staff about trends, safety alerts, and
current safety issues. Also, members
participated in a Patient Safety
Journal Club at monthly meetings

10. to examine evidence-based inter-
ventions from the literature. Finally,
the Fall Safety Team participated as
coaches and mentors in different
falls training events throughout the
hospital, including TeamSTEPPS
simulation and the semiannual
nursing skills validation fair.
Continuous Quality Improvement
January-February 2016 • Vol. 25/No. 1 19
Implementation of an Evidence-Based Patient Safety Team
FIGURE 1A.
Falls S.A.F.E.T.Y Team (FST) Post-Fall Checklist (1 of 2)
Directions: Please respond to unit within 30 minutes after fall
and complete the checklist. Once completed, scan to Falls
S.A.F.E.T.Y Team Folder and keep original. This information
will be used and discussed at next FST meeting.
Falls S.A.F.E.T.Y Team (FST) Representative Name:
Nurse, technician, and LVN caring for fallen patient Full Names
and Title:
Date and time of fall/discovery Date
Time
Date and time FST response Date Time
Fall location, room, and unit
Fall witnessed? Yes or No If yes give name:
Circle one: After fall, patient assisted to: Bed Chair Floor
Primary nurse description of environment and patient when

11. arriving to scene
Patient or family (if at bedside) description of fall
Please ask the following questions:
1. What was the patient trying to accomplish at time of fall?
2. Report from patient regarding injury (e.g., “my head
hurts”)
What was different this time compared to all other times you
did this activity without incident?
Any change in patient condition or injuries? Yes or No. If yes,
please explain in detail.
Describe injuries and location:
Have there been any changes to patient condition or plan of
care in last 24 hours? (e.g., new medications ordered,
received sedation)
Was provider notified? Yes or No If yes, what time? If no,
why not?
What was the patient’s activity order at the time of the fall?
Was this being followed?
What was the patient’s last assessed fall risk prior to the fall?
Were all corresponding nurse-initiated orders in place (NIO),
active, and signed off in treatment plan? (especially hourly
rounds)
MR#______________________
Fall Safety Team Simulation
Training

12. The Fall Safety Team worked with
unit leaders and the nursing services
patient safety officer to create and
facilitate an all-day TeamSTEPPS sim-
ulation training event titled “The
Perfect Storm: Falls Prevention using
EBP TeamSTEPPS.” Training includ-
ed an inpatient fall simulation sce-
nario in which participants conduct-
ed a bedside huddle, updated the
white board, and identified falls risk
factors. Participant surveys were
completed to evaluate the training,
and observers scored the use of dif-
ferent TeamSTEPPS principles in the
simulation. The 30-minute training
was completed by 17 groups of three
RNs, LVNs, and CNAs (military and
civilian). Feedback from the training
will serve as a baseline for future
TeamSTEPPS training and be used to
focus staff education on the most
common deficiencies seen in fall
simulation.
The Perfect Storm simulation sce-
nario was based on PSR data of fac-
tors contributing to falls. For exam-
January-February 2016 • Vol. 25/No. 120

13. ple, the most common event leading
to a fall was either the patient being
on the commode or transferring to
the toilet. The simulation empha-
sized the need to place a bedside
commode in the patient’s room, stay
with the patient while he or she was
on the toilet, and perform hourly
rounding. This was a key component
pertaining to PSR data utilization
and application with an evidence-
based approach, innovation, and
intervention. The TeamSTEPPS sim-
ulation feedback included critical
safety tasks missed in simulation as
well as evaluation of how well partic-
ipants demonstrated TeamSTEPPS
principles (see Table 1).
Results
The fall rate after the interven-
tion decreased to 0.69 falls per
1,000 bed days. A year after imple-
mentation, the average was 1.63
falls per 1,000 bed days (see Figure
2). These numbers were calculated
using PSR data and Workload
Management System for Nursing.
The current year-to-date falls rate
for the section was 1.63 falls per
1,000 bed days. This represents lim-
ited 3-month post-implementation
data; however, the change is clini-

14. cally relevant and continues to
trend downward. Attaining stake-
holder support, identifying unit-
level fall champions, and using
interactive and innovative educa-
tion platforms, creative marketing,
and leadership rounds minimized
project limitations.
Continuous Quality Improvement
FIGURE 1B.
Falls S.A.F.E.T.Y Team (FST) Post Fall Checklist (2 of 2)
FST Rep: ___________________________________ Date and
Time: _____________________
Bed alarm on? Yes or No
Was zone set for middle zone (Zone 2)? Yes or No
Was iBed in use? Yes or No
Comments:
Lines, tubing, drains present? Yes or No Comments:
Did patient have a mobility aid? Yes or No If yes, was it being
used?
Do patient have a sensory aid (hearing aids, glasses)?
Yes or No
If yes, was it being used.
Did patient’s clothes drag on the floor? Yes or No
Did patient have footwear? Yes or No Comments:
Restraint in place prior to fall? Yes or No If yes, was it being
used? Is in non-slip?
Bed in low position? Yes or No Comments:

15. Bed wheels locked? Yes or No Comments:
Wheelchair locked? Yes or No Comments:
Floor dry? Yes or No Comments:
Lighting adequate? Yes or No Comments:
Call light in reach? Yes or No Comments:
Bedside table, telephone, water container in reach?
Yes or No
Comments:
Area free of clutter and other items? Yes or No Comments:
Side rails in use? Yes or No
How many in use? 1 2 3 4 How many on bed? 1 2 3 4
Comments:
Were NIO’s being followed? Yes or No Comments:
If applicable, was mobility aid (e.g., walker, cane) working
properly? Yes or No
Comments:
Any environmental or safety issues? Yes or No Comments:
# Staff on duty? RN_____________ LVN_____________
CNA____________________ Tech__________________
Comments:
Did nurse complete a Patient Safety Report? Yes or No Unit
census and turnover for day ___
Recommendations from primary staff regarding possible
strategies to prevent this fall
Comments:

16. January-February 2016 • Vol. 25/No. 1 21
The Perfect Storm
Simulation Results
Observers scored the use of
TeamSTEPPS principles on a Likert
scale (1=completely ineffective, 5=very
effective). Two observations were
made about four different princi-
ples; for example, in assessing lead-
ership, observers determined if the
leader and participant roles were
well defined. Forty-nine individuals
participated in the Perfect Storm
Simulation and were asked to com-
plete surveys before and after train-
ing (see Figures 3 & 4). The pre-sur-
vey was completed by 49 individu-
als, of whom 85% (n=42) reported
receiving TeamSTEPPS 3.5 hour
training. Additionally, 95% (n=47)
indicated their respective inpatient
units demonstrate effective commu-
Implementation of an Evidence-Based Patient Safety Team
TABLE 1.
TeamSTEPPS Simulation Feedback and Evaluation
Key Principle Tools and Strategies Outcomes
Communication SBAR, call-out, check-back, handoff
Reduction in inpatient falls
Increase patient engagement

17. Adaptability
Team orientation
Collaborative care
Team performance
Increased staff confidence
Leadership Brief, huddle, debrief
Situation Monitoring STEP, I’M SAFEShared Mental Model
Patient-specific care plans
Advocacy and assertion
Facilitates patient trust
Mutual Support
CUS, Two-Challenge
Rule, task assistance,
feedback, DESC
TABLE 2.
Survey Results
Participant Pre-Simulation Survey Percentage of Yes Responses
Have you received TeamSTEPPS training? 85
Do you understand your role on the team when a patient falls on
your unit? 95
Do members of your work unit mutually support one another?
95
Participant Post-Simulation Survey
Mean Participant Score
3 = Strongly Agree
2 = Neutral
1 = Disagree

18. The team conducted a debrief after the fall simulation. 2.97
The team leader oriented (SBAR) the team prior to patient
engagement. 2.93
Team members mutually supported one another during the fall
simulation. 2.93
Team members used closed-loop communication during the
simulation. 2.84
Evaluator Survey of TeamSTEPPS Principle Score (1-5)
Leadership 4.22
Mutual support 4.50
Situation monitoring 4.20
Communication 4.15
Critical Safety Task Percentage of InterventionCompliance
Checked for non-skid socks 100
Updated white board 93
Activated falls response team 80
Used assertive communication: “Please do not get out of bed
without assistance.” 67
Checked call bell function 70
Completed falls risk education 47
Requested patient call bell use return demonstration 48
Used two patient identifiers 30
January-February 2016 • Vol. 25/No. 122
nication, mutual support, and situa-
tion awareness regarding prevention
fall strategies. Forty-five individuals
(92%) completed the post survey
and were asked to evaluate team
member use of TeamSTEPPS princi-
ples during the simulation. Co -

19. incidentally, observers and partici-
pants scored closed-loop communi-
cation the lowest at 2.84. Overall
communication, situation back-
ground assessment recommenda-
tion (SBAR), closed-loop, and
thoughts post fall scored a 2.90.
Participants scored themselves the
highest in leadership (debriefing
score mean=2.97), with mutual sup-
port and SBAR communication a
close second (mean=2.93).
The Fall Patient Safety Team has
been active since August 2013, with
plans to expand throughout the
surgical section. TeamSTEPPS simu-
lations are completed quarterly,
with the focus on replicating the
falls simulation training in other
sections throughout the organiza-
tion (e.g., critical care, periopera-
tive, surgical). The greatest chal-
lenge in completing simulation
training has been coordinating staff
schedules. Identification of two
runners, who went back to the
identified floor and escorted the
staff, facilitated timely simulation
training with a targeted team
approach. Additionally, each unit
received a schedule time to com-
plete the scenario.

20. Nursing Implications
This project suggests teamwork
and situational awareness are useful
in mitigating risk for falls and
improving patient safety in inpatient
clinical settings. Substantial evi-
dence supports EBP TeamSTEPPS
and its positive impact on patient
safety. The use of simulation training
for other patient safety and quality
improvements (e.g., medication
error prevention) can be replicated
for any patient care setting using a
team approach (team communica-
tion and teamwork). The EBP
TeamSTEPPS model can be used as
an intervention for any patient safe-
ty concern that requires hands-on
training. Authors recommend teams
and/or facilities identify the top
three patient safety events and casu-
Continuous Quality Improvement
FIGURE 2.
Medical Section Falls per 1,000 Bed Days
Fa
lls
p
er
1
,0
00
B

21. ed
D
ay
s
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
CY 2013
Jan Feb Mar Apr May June July Aug Sept
Medical Section falls
per 1,000 bed days
Average
pre-intervention
Average
post-intervention

22. FIGURE 3.
Participant Surveys
Pre-Simulation Survey
Please circle Yes or No
1. Have you received TeamSTEPPS training?
Yes or No
2. Do you feel empowered to communicate concerns on your
unit? Yes or
No
3. Do you participate in huddles and/or briefs at the beginning
of every shift? Yes or
No
4. Do you understand your role on the team when a patient falls
on your unit? Yes or No
5. Do members of your work unit mutually support one another?
Yes or No
Post-Simulation Survey
Please answer the questions below via the scale: 3 = Strongly
Agree, 2 = Neutral, 1 = Disagree
1. Team members effectively communicated their thoughts and
the plan following a fall. 3 2 1
2. The team leader oriented the team prior to patient
engagement using SBAR.
3 2 1
3. Team members used closed-loop communication during the
simulation. 3 2 1
4. The team conducted a debrief after the fall simulation.
3 2 1
5. Team members mutually supported each other thrughout the
simulation. 3 2 1

23. January-February 2016 • Vol. 25/No. 1 23
al factors. For example, if one of the
top three problems is falls then the
event and possible cause should be
reviewed (e.g., walking to the rest
room, using the commode, demen-
tia, incontinent bladder, continuous
intravenous fluids). Team members
should collaborate to identify evi-
dence-based interventions to include
in simulation training.
Conclusion
Consistency has been the key to
hardwiring these concepts into day-
to-day operation on the nursing
units. The falls safety team has since
become part of the Depart ment of
Nursing Patient Safety Team and
received extensive patient safety
training (TeamSTEPPS Master Train -
er Course [2.5-8 hour days] and
Patient Safety Workshop [1-8
hours]). The Patient Safety Team
will continue to respond to falls,
complete the post-fall assessment
checklist, make recommendations,
and tailor interventions based on
best evidence. The team also will
continue to participate in depart-
ment or section-level education and

24. training related to falls and other
patient safety issues. Overall, the
Patient Safety Team works to inte-
grate TeamSTEPPS at the bedside to
gain the trust of patients, family
members, and fellow team mem-
bers. Although all inpatient falls
may not be preventable, impact can
be made by raising situational
awareness, increasing mutual sup-
port, engaging leaders, encouraging
open communication, and provid-
ing frontline staff education and
involvement. This EBP intervention
has reduced the probability of
patient harm and has made a
notable clinical contribution to falls
prevention. Timely frontline staff
feedback; visible, engaged, and sup-
portive leadership; and transparen-
cy proved extremely valuable
throughout the entire project.
REFERENCES
Boltz, M., Capezuti, E., Wagner, L.,
Rosenberg, M.C., & Secic, M. (2013).
Patient safety in medical-surgical units:
Can nurse certification make a differ-
ence? MEDSURG Nursing, 22(1), 26-
37.
Bouldin, E.L.D., Andresen, E.M, Dunton, N.E.,
Simon, M., Waters, T.M., Liu, M., &
Shorr, R.I. (2013). Falls among adult

25. patients hospitalized in the United
States: Prevalence and Trends. Patient
Safety, 9(1), 13-17.
Carter, K., & Burnette, H. (2011). Creating
patient-nurse synergy on a medical-sur-
gical unit. MEDSURG Nursing, 20(5),
249-254.
DuPree, E., Fritz-Campiz, A., & Musheno, D.
(2014). A new approach to preventing
falls with injuries. Journal of Nursing
Care Quality, 29(2), 99-102.
Graham, B.C. (2012). Examining evidence-
based interventions to prevent inpatient
falls. MEDSURG Nursing, 21(5), 267-
274.
Olrich, T., Kalman, M., & Nigolian, C. (2012).
Hourly rounding: A replication study.
MEDSURG Nursing, 21(1), 23-26.
Peer, K., & Rakich, J. (2000). Accreditation
and continuous quality improvement in
athletic training education. Journal of
Atheletic Training, 35(2), 188-193.
Tzeng, H.M., & Yin, C.Y. (2012). Toileting-
related inpatient falls in adult acute care
settings. MEDSURG Nursing, 21(6),
372-377.
Shugdar, M. (n.d.) The FOCUS-PDCA
methodology. Retrieved from http://
www.cbahi.org/rm/files/Standards/QM/

26. Teaching%20Samples/07.7%20QM%20
FOCUS%20Summry.pdf
Williams, T., Szekendi, M., & Thomas, S.
(2014). An analysis of patient falls and
fall prevention programs across academ-
ic medical centers. Journal of Nursing
Care Quality, 29(1), 19-29.
Implementation of an Evidence-Based Patient Safety Team
FIGURE 4.
“The Perfect Storm” Evaluator Score Sheet
Leadership
Notes/Comments:
1. How effective was the team in establishing a
team leader clear throughout the scenario?
1 2 3 4 5
2. How effective was the team in defining and
maintaining clear roles throughout the sce-
nario?
1 2 3 4 5
Mutual Support
Notes/Comments:
1. Did the staff remain calm, friendly, and sup-
portive throughout the entire scenario?
1 2 3 4 5
2. How effective were team members in verbal-

27. izing concerns and supporting each other
throughout the scenario?
1 2 3 4 5
Situation Monitoring
Notes/Comments:
1. How effective was the team in cross monitor-
ing for each other (monitoring each other and
sharing workload)?
1 2 3 4 5
2. How effective was the team in demonstrating
situation monitoring and reacting appropri-
ately?
1 2 3 4 5
Communication
Notes/Comments:
1. How effective was the staff in repeating back
information and making sure communication
was complete?
1 2 3 4 5
2. How effectively did team members use SBAR
to communicate with those entering the sce-
nario?
1 2 3 4 5
1 = completely ineffective, 2 = ineffective, 3 = neutral, 4 =
effective, 5 = very effective

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