penelitian kk 4.pdf

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ORIGINAL CONTRIBUTION

Role of ComputerizedPhysician Order Entry Systemsin Facilitating Medication ErrorsRoss Koppel, PhD

Joshua P. Metlay, MD, PhD

Abigail Cohen, PhD

Brian Abaluck, BSA. Russell Localio, JD, MPH, MS

Stephen E. Kimmel, MD, MSCE

Brian L. Strom, MD, MPH

ADVERSE DRUG EVENTS (ADES)are estimated to injure or killmore than 770000 people inhospitals annually.1 Prescrib-

ing errors are the most frequentsource.2-5 Computerized physician or-der entry (CPOE) systems are widelyviewedas crucial for reducing prescrib-ing errors2,3,6-17 and saving hundreds ofbillions in annual costs.18,19 Comput-erized physician order entry systemadvocates include researchers, clini-cians, hospital administrators, phar-macists, business councils, the Insti-tute of Medicine, state legislatures,health care agencies, and the lay pub-lic.2,3,6-10,12,14-17,20-22 These systems areexpected to become more prevalent inresponseto resident working-hour limi-tations and related care discontinui-ties23 and will supposedly offset causes(eg, job dissatisfaction) and effects

(eg, ADEs) of nursing shortages.24,25Such a system is increasingly recom-mended for outpatient practices (BOX).

Adoption of CPOE perhaps gath-ered such strong support because itspromise is so great, effects of medica-

See also pp 1223 and 1261.

Author Affiliations: Departmentof Sociology (Dr Kop-pel), Department of Medicine, Cardiovascular Divi-sion (Dr Kimmel) and General Medicine Division (DrsMetlay and Strom), Center for Clinical Epidemiologyand Biostatistics (Drs Koppel, Metlay, Cohen, Kim-mel, and Strom and Mr Localio), Department of Bio-statistics and Epidemiology (Drs Metlay, Kimmel,andStrom and Mr Localio), Department of Pharmacol-ogy (Dr Strom), Center for Education and Research

in Therapeutics (Drs Metlay and Strom and Mr Lo-calio), University of Pennsylvania School of Medicine(Mr Abaluck),Philadelphia;and Center for Health Eq-uity Research and Promotion, Department of Veter-ans Affairs, Philadelphia (Dr Metlay).Corresponding Author: Ross Koppel, PhD, Center forClinicalEpidemiology and Biostatistics, Room 106,Block-ley Hall, School of Medicine, University of Pennsylva-nia, Philadelphia, PA 19104([email protected]).

Context Hospital computerized physician order entry (CPOE) systems are widely re-garded as the technical solution to medication ordering errors, the largest identifiedsource of preventable hospital medical error. Published studies report that CPOE re-duces medication errors up to 81%. Few researchers, however, have focused on the

existence or types of medication errors facilitated by CPOE.Objective To identify and quantify the role of CPOE in facilitating prescription errorrisks.

Design, Setting, and Participants We performed a qualitative and quantitativestudy of house staff interaction with a CPOE system at a tertiary-care teaching hos-pital (2002-2004). We surveyed house staff (N=261; 88% of CPOE users); con-ducted 5 focus groups and 32 intensive one-on-one interviews with house staff, in-formation technology leaders, pharmacy leaders, attending physicians, and nurses;shadowed house staff and nurses; and observed them using CPOE. Participants in-cluded house staff, nurses, and hospital leaders.

Main Outcome Measure Examples of medication errors caused or exacerbatedby the CPOE system.

Results We found that a widely used CPOE system facilitated 22 types of medica-tion error risks. Examples include fragmented CPOE displays that prevent a coherentview of patients medications, pharmacy inventory displays mistaken for dosageguidelines, ignored antibiotic renewal notices placed on paper charts rather than inthe CPOE system, separation of functions that facilitate double dosing and incompat-ible orders, and inflexible ordering formats generating wrong orders. Three quartersof the house staff reported observing each of these error risks, indicating that theyoccur weekly or more often. Use of multiple qualitative and survey methods identi-fied and quantified error risks not previously considered, offering many opportunitiesfor error reduction.

Conclusions In this study, we found that a leading CPOE system often facilitatedmedication error risks, with many reported to occur frequently. As CPOE systems areimplemented, clinicians and hospitals must attend to errors that these systems causein addition to errors that they prevent.

JAMA. 2005;293:1197-1203 www.jama.com

2005 American Medical Association. All rights reserved. (Reprinted) JAMA, March 9, 2005Vol 293, No. 10 1197

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tion error so distressing, circum-stances of medication error so prevent-able, and studies of CPOE preliminaryyet so positive.21,26-28 Studies of CPOE,however, are constrained by its com-parative youth, continuing evolution,need to focus on potential rather than

actual errors, and limited dissemina-tion (in 5% to 9% of US hospitals).29-36

Two critical studies21,30 examined dis-tinctions between reductions in pos-sible ADEs vs actual reductions inADEs; the former are well docu-mented and often cited, but the latterare largely undocumented and un-known. Studies of CPOE efficacy (17%to 81% error reduction) usually focuson its advantages2,3,6-11,14-16 andare gen-erally limited to single outcomes, po-tential error reduction, or physician sat-

isfaction.

28,30,34-40

Often studies combineCPOE and clinical support systems intheir analyses.30,40,41

Inthe past 3 years,though, a few stud-ies21,26-28,30,31,33,42-46 suggested some waysthat CPOE might contribute to medica-tionerrors(eg, ignoredfalsealarms,com-puter crashes, ordersin thewrong medi-cal records). Several decades of human-

factors research, moreover, highlightedunintended consequences of techno-logic solutions, with recent discussionson hospitals.32,33,42-44,47-52

We undertook a comprehensive,multimethod study of CPOE-relatedfactors that enhance risk of prescrip-

tion errors.

METHODS

Design

We perf or med a quan ti ta ti ve andqualitative study incorporating struc-tured interviews with house staff,pharmacists, nurses, nurse-managers,attending physicians, and informa-tion technology managers; real-timeobservations of house staff writingorders, nurses charting medications,

and hospital pharmacists reviewingorders; focus groups with house staff;and written questionnaires adminis-tered to house staff. Qualitativeresearch was iterative and interactive(ie, interview responses generatednew focus group questions; focusgroup responses targeted issues forobservations).

Setting

We studied a major urban tertiary-careteaching hospital with 750 beds, 39000annual discharges, and a widely usedCPOE system (TDS) operational therefrom 1997 to 2004. Screens were usu-

ally monochromatic with pre-Win-dows interfaces (EclipsysCorp,Boca Ra-ton, Fla).Thesystem wasusedonalmostallservices andintegrated with the phar-macys and nurses medication lists.

This study was approved by theUni-versity of Pennsylvania institutional re-view board. The researchers were notinvolved in CPOE system design, in-stallation, or operation.

Data Collection

Intensive One-on-One House StaffInterviews. To develop our initial ques-

tions, we conducted 14 one-on-onehouse staff interviews. An experi-enced sociologist (R.K.) conducted theopen-ended interviews, focusing onstressors and other prescribing-errorsources (mean interview time, 26 min-utes; range,14-66 minutes).

Focus Groups. We conducted 5 fo-cus groups with house staff on sourcesof stress and prescribing errors, moder-atedby an experienced sociologist(R.K.)and audiorecorded.Participants werere-imbursed $40 (average group size, 10;

range, 7-18; and average length, 1.75hours; range, 1.4-2 hours).

Expert Interviews. We interviewedthe surgery chair, pharmacy and tech-nology directors, clinical nursing di-rector, 4 nurse-managers, 5 nurses, aninfectious disease fellow, and 5 attend-ing physicians. All interviews, except1, were privately conducted by thesameinvestigator (R.K.).

Shadowing and Observation. Dur-ing a discontinuous 4-month period(2002-2003),weshadowed 4 house staff,

3 attending physicians,and 9 nursesen-gagedin patient care andCPOE use. Weobserved 3 pharmacists reviewing or-ders. The researcher (R.K.) wore a fac-ulty identification badge. Observationnotes were freehand but guided by theinterview findings.

Survey. From 2002 to thepresent, wedistributed structured, self-adminis-

Box. Advantages of CPOE Systems Compared With Paper-Based

Systems1,2,6-9,11,13-15

Free of handwriting identification problems

Faster to reach the pharmacy

Less subject to error associated with similar drug names

More easily integrated into medical records and decision-support systems

Less subject to errors caused by use of apothecary measures

Easily linked to drug-drug interaction warnings

More likely to identify the prescribing physician

Able to link to ADE reporting systems

Able to avoid specification errors, such as trailing zeros

Available and appropriate for training and education

Available for immediate data analysis, including postmarketing reporting

Claimed to generate significant economic savings

With online prompts, CPOE systems can

Link to algorithms to emphasize cost-effective medications

Reduce underprescribing and overprescribingReduce incorrect drug choices

Abbreviations: ADE, adverse drug event; CPOE, computerized physician order entry.

COMPUTERIZED ORDER ENTRY SYSTEMS AND MEDICATION ERRORS

1198 JAMA, March 9, 2005Vol 293, No. 10 (Reprinted) 2005 American Medical Association. All rights reserved.



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an existing medication. Without dis-continuing the current dose, physi-cians can increase or decrease medica-tion (giving a double total dose, eg,every 6 hours and every 8 hours), addnew but duplicative medication, and

add conflicting medication.Medication-canceling ambiguities are exacerbatedby the computer interface and multiple-screen displays of medications; as dis-cussed below, viewing 1 patients medi-cations may require 20 screens.

Discontinuation failures for at leastseveral hours from not seeing pa-tients complete medication recordswere reported by 51% (Table). Twenty-two percent indicated that this failureoccurs a few times weekly, daily, or morefrequently.

Procedure-Linked Medication Dis-

continuation Faults. Procedures andcertain tests are often accompanied bymedications. If procedures are can-celed or postponed,no software link au-tomatically cancels medications.

Immediate Orders and Give-as-Needed Medication DiscontinuationFaults. NOW (immediate) and PRN(giveasneeded) orders maynot enter theusual medication schedule and are sel-domdiscussedat handoffs.Also, becausemedication charting is so cumbersomeand displays so fragmented, NOW and

PRNorders are less certain to be chartedor canceled as directed. Failure to chartor cancel canresultin unintended medi-cations on subsequent days or reorder-ing (duplications) on the same day.

Antibiotic Renewal Failure. To maxi-mize appropriate antibiotic prescrib-ing, house staff arerequiredto obtain ap-proval by infectious disease fellows orspecialist pharmacists. Lack of coordi-nationamong informationsystems, how-ever, can produce gaps in therapy be-cause antibioticsare generally approved

for3 days. Beforethe third day, house staffshould request continuation or modifi-cation. To aid this process, reapprovalstickers are placedon paper chartson thesecond day. However, when house stafforder medications, they primarily useelectronic charts, thus missing warningstickers. No warning is integrated intotheCPOEsystem, and ordering gaps ex-

pand until noticed. Some unintentionalgaps continue indefinitely because itis unknown whether antibiotics were in-tentionally halted.. In thelast 3 months,83% of house staff observed gaps in an-tibiotic therapy because of unintended

delays in reapproval. Twenty-seven per-cent reportedthis occurrence a fewtimesweekly; 13%, once daily or more fre-quently (Table).

Diluent Options and Errors. A re-cent CPOE innovation requires housestaff to specify diluents (eg, saline so-lution) for administering antibiotics. Afew diluents interact with antibiotics,generating precipitates or other prob-lems. Many house staff are unaware ofimpermissible combinations. Pharma-cists catch many such errors, but theirinterventions are time-consuming and

not ensured.Allergy Information Delay. CPOE

provides feedbackon drug allergies, butonly after medications are ordered.Some house staff ignored allergy no-tices because of rapid scrolling throughscreens, the need to order many medi-cations, difficulties discontinuing andreordering medications, possibility offalse allergy information, and, most im-portant, post hoc timing of allergy in-formation. House staff claimed posthocalertsunintentionally encourage house

staff to rely on pharmacists for drug-allergy checks, implicitly shifting re-sponsibility to pharmacists.

Conflicting or Duplicative Medi-cations. The CPOE system does notdisplay information available on otherhospital systems. For example, only thepharmacyscomputerprovidesdruginter-action andlifetimelimitwarnings. Phar-macists call house staff to clarify ques-tionable orders, but this additional stepcosts time and increases error potential.Housestaff andpharmacistsreportedthat

this method generates tension.Human-Machine Interface Flaws:

Machine Rules That Do Not

Correspond to Work Organization

or Usual Behaviors

Patient Selection. Itis easyto selectthewrong patient file because names anddrugsareclosetogether, thefont issmall,

and, most critical here, patients namesdo not appear on all screens.. DifferentCPOE computer screens offer differ-ing colors and typefaces for the sameinformation, enhancing misinterpre-tation as physicians switch among

screens.Patients names are grouped alpha-betically rather than by house staffteams or rooms. Thus, similar names(combined with small fonts, hecticworkstations, and interruptions) areeasily confused.

Fifty-five percent of house staff re-ported difficulty identifying the pa-tient they were ordering for because offragmented CPOE displays; 23% re-ported that this happened a few timesweekly or more frequently (Table).

Wrong Medication Selection.Apa-

tients medication information is sel-dom synthesized on 1 screen. Up to 20screens might be needed to see all of apatients medications, increasing thelike-lihood of selecting a wrong medication.

Seventy-two percentof house staff re-ported that they were often uncertainabout medications and dosages be-cause of difficulty in viewing all themedications on 1 screen.

Unclear Log On/Log Off. Physi-cians can order medications at com-puter terminals not yet logged out by

the previous physician, which can re-sult in either unintended patients re-ceiving medication or patients not re-ceiving the intended medication.

Failure to Provide MedicationsAfter Surgery. When patients un-dergo surgery, CPOE cancels their pre-vious medications. When surgeons or-der new or renewed medications,however, the orders are suspended(not sent to the pharmacy) until acti-vated by postanesthesia-care nurses.But these activations still do not dis-

pense medications. Physicians must re-enter CPOE and reactivate each previ-ously ordered medication. Surgeryresidents reported that they some-times overlooked this extra process.

Postsurgery Suspended Medica-tions. Physicians ordering medica-tions for postoperative patients whomthey actually observe on hospital floors





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can be deceived by patients real loca-tion vs patients computer-listed loca-tion. If patients were not logged out ofpostanesthesia care, the CPOE will notprocess medication orders, labelingthemsuspended. Physicians must re-

negotiate the CPOE and resubmit or-ders for patients to receive postsurgi-cal medications.

Loss of Data, Time,and Focus WhenCPOE Is Nonfunctional. CPOE isshutdown for periodic maintenance, andcrashes are common. Backup systemsprevent loss of data previously en-tered. However, orders being enteredwhen the system crashes are lost andcannot be reentered until the system isrestarted. House staff reported that theneed to wait for the systems revival andorder reentry increases error risks.

Eighty-four percent reported de-layed medication orders because of sys-tem shutdowns. Forty-seven percent re-ported that shutdowns occur a fewtimes weekly to more than once daily(Table). The CPOE manager con-firmed house staff downtime esti-mates; 2 or 3 weekly crashes of at least15 minutes are common.

Sending Medications to WrongRooms When the Computer SystemHas Shut Down. If the computer sys-tem is down when a patient is moved

withinthe hospital,CPOE does notalertthe pharmacy, and medications are sentto the old room, thus being lost or de-layed. Also, wrong medications mightbe administered to new patients inold rooms.

Late-in-DayOrdersLostfor24 Hours.When patients leave surgery or are ad-mitted late in the day, medications andlaboratoryordersmight be requested fortomorrow at,forexample, 7 AM. By thetime the intern enters the orders, how-ever, it might already be tomorrow (ie,

after midnight). Therefore, patients donot receive medications or tests for anextra day.

Role of Charting Difficulties in In-accurate and Delayed MedicationAdministration. Nurses are required torecord (chart) administration of medi-cations contemporaneously. However,contemporaneous charting requires

time when there is little time avail-able. Computerizedphysician order en-try systems compound this challengeconsiderably. To chart drug adminis-trations, nurses must stop administer-ingmedications,find a terminal, logon,

locate that patients record, and indi-vidually enter each medications ad-ministration time. If medications arenotadministered (eg, patient wasout of theroom), nurses must scroll through sev-eral additional screens to record the rea-son(s) for nonadministration.

Nurses reported that up to 60% oftheir medications are not recordedcon-temporaneously but arecharted at shiftend or post hoc by the nurse managervia global computer commands.

Many house staff, aware of record-ing inaccuracies, seek nurses to deter-

mine real administration times of time-sensitive drugs (eg, aminoglycosides).House staff reported that these addi-tional steps are distracting and time-consuming. Interrupted ordering ormedication reviews can increase errorrisks.

Moreover, because of cumbersomecharting, some medications, espe-cially insulin, are recorded on parallelsystems (ie, paper chart, separate pa-per sheets, or directly in CPOE). Mul-tiple systems cause confusion, and off-

system information is sometimes lost.Inflexible Ordering Screens, Incor-

rect Medications. House staff re-ported that because of CPOE inflex-ibility, nonstandard specifications (eg,test modifications or specific scanangles) are often impossible to enter.Medications accompanying proce-dures must be stopped and reordered,with dangers linked to uncertain can-celing and reordering.

Similarly, nonformulary medicationscan be lost because they must be en-

tered on separate screen sections, mightnot be sent to the pharmacy, and mightescape nurses notice (eg, nonformu-lary medication to prevent organ rejec-tion was not listed among medicationsin CPOE, was not sent to the pharmacy,and was ignored for 6 days).

Ninety-two percent reported thatCPOE is inflexible, generating difficul-

ties in specifying medications or order-ing off-formulary medications. Thirty-one percent reported that this occurreda few times weekly; 24% said daily ormore frequently (Table).

COMMENT

Our qualitative research identified 22situations in which CPOE increasedtheprobability of prescribing errors. Ourquantitative data reveal that severalCPOE-enhanced error risks appearcommon (ie, observed by 50% to 90%of house staff) andfrequent (ie, repeat-edly observed to occur weekly or moreoften). We broadly grouped the errorrisks as information errors generatedbyfragmentation of data and failure to in-tegrate the hospitals several com-puter and information systems (10 er-

r o r ty pes) and hum an- m achi neinterface flaws reflecting machine rulesthat do not correspond to work orga-nization or usual behaviors (12 errortypes). Although this schema is not ex-haustive, it informs both administra-tive and programming solutions.

Perhaps CPOE-facilitated error risksreceived limited attention because themethodologies and fociof previousstud-ies addressed CPOEs role in error re-duction2,3,6-11,14-16,42 and seldom its rolein error facilitation.21,26-28,31,32,45 Onekey

study27

examined errors but was en-tirely qualitative, with no frequency es-timates. Other reasons CPOEs prob-l e m s m a y h a v e e s c a p e d l a r g e rexamination include the orientation ofmedical personnel to solve or workaround problems, beliefs that prob-lems are due to insufficient training ornoncompliance, erratic error-report-ing mechanisms, and focus on technol-ogy rather than on work organiza-tion.30,32,42,43,52,53 Our multimethod,triangulated approach explored wider

ranges of CPOEs effects.

33,42,48,54

That CPOE use might increase thelikelihood of medication errors was anunanticipated finding,which would nothave surfaced without open-endedqualitative research. Survey data pro-vided a different type of validation andstrengthened our confidence in thefindings. Our error risk frequency es-





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timates are from a robust sample ofhouse staff.

We conducted researchat only 1 hos-pital. Although theCPOEsystem we ex-amined (TDS) has comprised as muchas 60% of the market,55-57 it is possible

that several CPOE-facilitatederrors dis-cussed here may not be widely gener-alizable. Also, TDS, like all complexCPOEsystems, is customized and un-dergoes repeated improvements. Ourqualitative findings are not from ran-dom house staff samples. Identified er-ror risks may be overstated or under-stated.However, our survey findings arebased on an almost 90% sample of rel-evant house staff and are less likely sus-ceptible to sample bias.

House staff may have misinter-preted our questions or response cat-

egories. Despite extensive pretests, fo-cus groups, and poststudy interviews,the process is hardly foolproof.

Although house staff in one-on-oneinterviews and focus groups discussedactual errors, the survey data reflecthouse staff responses or statementsabout medication error likelihood, notactual ADEs. Thus, our survey analysisfocuses on features of error-prone sys-tems rather than errorsthemselves. Also,we stress that hospital pharmacists re-view every order and reject about 4%;

many errors existed with paper-basedsystems, and without direct compara-tive studies wecannotcontrasttheir rela-tive advantages; there isno reasonto sus-pect that TDS is inferior to any otherCPOE system; and it is badly designedand poorly integrated CPOE systemsthat are at issue.

CPOE is widely regarded as the cru-cial technology for reducing hospitalmedication errors.2,3,6-22,30,31,58,59 As withany new technology, however, initialas-sessments may insufficiently consider

risks and organizational accommoda-tions.* The literature on CPOE, withfew exceptions,21,26-28,34,39,45 is enthusi-astic. Our findings, however,reveal thatCPOE systems can facilitate error risksin addition to reducing them. With-out studies of the advantages and dis-

advantages of CPOE systems, research-ers are looking at only one edge of thesword. This limitation is especially note-worthy because many problems weidentified are easily corrected.

Ourrecommendationsconcentrate on

organizational factors. (1) Focus pri-marily on the organization of work, noton technology; CPOE must determineclinical actions only if they improve, orat least do not deteriorate, patient care.(2) Aggressively examine the technol-ogy in use; problems are obscured byworkarounds, the medical problem-solving ethos, and low house staff sta-tus.(3) Aggressivelyfix technology whenit is shown to be counterproductivebecausefailureto do so engenders alien-ation and dangerous workarounds inaddition to persistent errors; substitu-

tion of technology for people is a mis-understandingofboth. (4)Pursueerrorssecond stories and multiple causa-tions to surmount thebarriersenhancedbyepisodicandincompleteerror report-ing, which is standard, and manage-ment beliefin theseerror reports, whichobfuscates and compounds problems.(5) Plan for continuous revisions andquality improvement, recognizing thatall changes generate new error risks.

In our work, use of multiple quali-tative and survey methods identified

and quantified error risks not previ-ously considered, offering many op-portunities for error reduction. AsCPOE systems are implemented, clini-cians and hospitals must attend to theerrors they cause, in addition to the er-rors they prevent.

Author Contributions: Dr Koppelhad full accessto allof the data in the study and takes responsibility forthe integrity of the data and the accuracy of the dataanalysis.Study concept and design: Koppel, Metlay, Localio,Kimmel, Strom.Acquisition of data:Koppel, Cohen, Abaluck, Localio.Analysis and interpretation of data: Koppel, Cohen,

Abaluck, Localio.Drafting of the manuscript: Koppel, Cohen.Critical revision of the manuscript for important in-tellectual content: Koppel, Metlay, Cohen, Abaluck,Localio, Kimmel, Strom.Statistical analysis: Koppel, Cohen.Obtained funding: Koppel, Metlay, Localio, Kimmel,Strom.Administrative, technical, or material support:Koppel,Cohen, Localio, Strom.Study supervision: Koppel, Cohen, Strom.Financial Disclosures: None reported.

Funding/Support: This research was supported by agrant from the Agency for Healthcare Research andQuality (AHRQ), P01 HS11530-01, Improving Pa-tient Safety Through Reduction in Medication Errors.Dr Metlayis also supportedthroughan AdvancedRe-search Career Development Award from the HealthServices Researchand DevelopmentService of theDe-partment of Veterans Affairs.Role of theSponsors: Neither AHRQnor theDepart-

ment of Veterans Affairs had any role in the designand conduct of the study; collection, management,analysis, and interpretation of the data; or the ap-proval of the manuscript.Project AdvisoryCommittee: LindaH. Aiken,PhD,Uni-versity of Pennsylvania; David W. Bates, MD, MSc,Harvard School of Medicine; Shawn Becker, RN, USPharmacopeia; Marc L. Berger, MD, Merck & Co;StevenL. Sauter, PhD, National Institute forOccupa-tional Safety and Health; Thomas Snedden, PA, De-partment of Aging; Paul D. Stolley, MD, MPH, Uni-versity of Maryland; Joel Leon Telles, PhD, DelawareValley Healthcare Council of Hospital Association ofPennsylvania.Acknowledgment: We thank Charles Leonard,PharmD; Frank Sites, MHA, RN; Joel Telles, PhD; Ed-mund Weisburg, MS; and Ruthann Auten, BA.

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