The woes of new prescriptions

Lets face it, pharmacists are between a rock and a hard place when it comes to new prescriptions.  To be more blunt like this, we get bent over and the only choice is between what brands of lube we do (or dont) get.

Verbal Call Ins:
Usually from someone who has close to zero medical knowledge, these abortions of our profession are littered with “I think that’s….” or “Does … exist?” by some high-school student who is trying to decipher the same handwriting that took us a college degree to learn.  Add onto the fact that most doctors are notoriously cheap (or foreign) thereby hire the bottom of the barrel staff who either know nothing, don’t speak English clearly, mumble, speak softly or all of these.  Although I thought that having Methotrexate 0.2 mg called in by an OB/GYN was a mistake, it however didn’t take the office staff to say “Well I couldn’t really read it” when I called back to make damn sure they meant Methergine.  Now only an idiot can confuse MTX with Methergine, but the point is still there.

Now there isn’t a good way to handle this short of having the prescriber him/her/itself call in.  However, there are a TON of doctors who I cant understand what the hell they are saying, so we’re back to square one.  The prescriber can however hire people who speak CLEAR and LOUD english on the telephone.  However if their girls misspoke on the phone and someone dies, unless pharmacies have call recording software nothing will happen to the MD and his marble-mouthed liability.  They will just show on the chart it was written correctly, taken verbally by Pharmacist-X and that’ll be the end of their accountability.  Pretty sad to know that your career/livelihood is being held by some idiot who cant point to where her rectum is.

So, solutions?  One is pretty damn good that I came up with all by myself (go me).  If a doctors office has someone call in an Rx that you cant understand what the fuck they are talking about, tell them “Excuse me, but I cant understand a word you are saying.  Is there someone there who can call in the Rx for you?”  Sure you’ll offend the person on the phone, but both herself and the Dr should KNOW BETTER.  If the Dr gets pissed, ask if you would like that person calling in Rx’s for his/her family.  See, Dr’s like to get pissed off about things, but most of the time if you hit them with the logic bat (ie: ITS UNSAFE) then they can be pretty receptive.  I’d rather hurt the feelings of some young “nurse” who cant speak the English than hurt the feelings of an entire family because she called in something incorrectly and killed someone.  If we stand up and address the problem then it won’t be as big of a problem.  If we just accept it and let them vowel-guess us to death then it’s just going to get worse.

Now not to belittle techs, but lets imagine a time when a Tech can get a New-Rx over the phone by one of these marble-mouthed idiots.  Yikes!  That right there is pharmacist double-penetration with no lube.

Because today’s society we are so afraid to say to people that they cant speak clear English. Some company (and computer programmers who have NEVER EVER EVER stepped foot in a pharmacy for more than 20 min) created ePrescribing (such as SureScripts)

I’m not going to go into how absolutely EASY it is for anyone who has ever worked in a doctors office to call in phony Rx’s.  Hell, with how substandard the people calling in Rxs have gotten I would take a new one from an autistic dog for Norco without any suspicion (that’s if they actually called it by Norco, instead of Vicodin 5/325 *sigh*).

Seriously doctors, make your life and mine a whole lot easier (and safer for your patients), hire someone who knows what the fuck they are doing.

ePrescribing:
Touted as the next best thing since prepackaged drugs, the ePrescribing system is going to become mandatory in a couple of years.  All doctors will be able to go to their computers, click away and have their Rx magically zipped to the pharmacy of their choice!

Like taxes and welfare, this is a system that looks better on paper than how it really is.  Take this example to my right. 
erx-levaquin.jpg 

Now I’m not sure about you, but if I were some tech who didn’t know any
better and was just hammering out the Rx’s while my pharmacist sat around and drank coffee, I would fill that as Levaquin 750 #5 – 1 tablet 4 times daily.  Thats what it says right?  Now all of the pharmacists reading at home are giggling, the doctors are sighing, and the dentists are wondering what the problem with this Rx is :).   Now I’ve been out of school for a while, so there might be some indication for 750mg of levaquin 4 times a day.  Wait, there is.  Its called WRONGITITS.  Its called the QD and QID drop-down boxes were so close together that someone clicked the wrong fucking one and the Rx was verified and sent out (by the “Dr”).  If a tech filled that and the pharmacist wasn’t on his game, that would of went out vs having the pharmacist on the phone saying “4 times a day? You’re on crack girl-who-cant-speak-english!”  How would their software even allow that to go out with such a blantant mistake?  This isn’t rocket science folks, certain drugs are commonly taken either once or twice daily.  Its very RARE we see a modern (ie: still trade name only) drug that has to be taken 4 times a day.

Is there a cut and dry solution to this problem? Yeah, give pharmacists prescriptive authority like you’ve given everyone else with letters after their names. :)

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39 Comments

  1. Love says:

    ‘Round these parts, only people with a legal right to write prescriptions can call them in, which means that when we pick up the phone to jot down a phone prescription, we talk to the person responsible for it. Sure, they are sometimes hard to understand, but at least you have them on the other end of the line so you can ask them to repeat things.
    As for ePrescribing, it’s really big here. REALLY big. I would guess that 80+% of the scripts we get these days are e-scripts. And the system here is easy to use and easy to understand. It does happen that doctors tick the wrong box, but not very often.

  2. rph3664 says:

    E-prescribing is really going to put our educations to the test.

  3. newpharmd says:

    You forgot to add that the PAs and NPs are clicking away on their PDAs trying to figure out what the problem is :)

  4. Google Account says:

    Software can be written so that only the standard is an option and the doctor has to override for anything else. For example, the levaquin would only have a QD option. It could also be written so only the doses commonly available for each med would show. Another way the software could be written is it could require the weight be given for any weight based dosing.
    We need a really good standardized software program that was developed in conjunction with pharmacists. And it needs to be inexpensive enough that doctors will actually buy it. and user friendly enough that they will use it.

  5. amber says:

    Thanks TAP for this rant, actually I’m quite glad you put it up as it relates to an incident I had on Friday. I’m still not sure if I wanted to just go the a*hole cardiologist’s office and just kick’em in the balls or submit an actual complaint to the Board of Medical Examiners, but I do prefer the first option. However, I wanted to see if anyone else had to deal w/ something like this…
    Hand-written script was turned in for Keflex 500, 1 tab Q6h for quan 8. Now I’ve seen this before, usually from a dentist’s office for prophylaxis (which is usu to take 4 caps an hour before appt or something along those lines) , etc. But seeing as this was from a cardio doc and the patient telling me that his wife just had a pacemaker put in, AND being in a retail setting, not having any discharge papers infront of me to tell me what the patient had in the hospital or for how many days, I decided to call and just be sure the 8 wasn’t a real bad 20 ( hey it’s been known to happen) for post-op a/b therapy. Just to make sure, cuz unfortunately deep down, I DO care about the patient.
    After getting the run-around from secretaries, med-assistants, nurses (including having to FAX the script to the office twice cuz they couldn’t find it in the chart)and leaving 3 msgs, the a*hole doctor calls me, tells me it’s 20, then scoffs at me, tells me I’m on drugs and a moron, and obviously it’s an 8, doesn’t want to know why I questioned it but obviously I don’t know my shit and how dare I waste his time. (yes he did say that ” How dare you waste my time”) I was so peeved off I think I blanked out for a few minutes. I mean I’ve had to deal w/ shit-faced docs before, but this guy was unfucknbelivable!! So much for professional collaboration…guess we should just blindly fill anything & everythin ..go figure

  6. Eric says:

    Md’s around here use e-scribing called dr first. The drug comes with a pre-entered sig but the doctor can add one. The rx usually comes out with 2 sets of directions since the doctor never removes the old ones. Or how about the moron who leaves a message on the dr line for 6 rx’s as fast as she can talk without taking a breath. “Hey, you are waste of oxygen, do you realize we actually have to write down what you say?”

  7. It’s high time for doctor’s “office (nurses)(workers)(assistants)” to have to get licensed as pharmacy technicians. As you so aptly described, TAP, there is just too much at stake for this work to be done by unlicensed, unskilled people. It has always been a “good idea” to get the name of the physician’s agent, but it should be a required part of the documentation trail: name of pharmacist, name of physician, name of agent.
    It is also time for pharmacy software to be updated so that the abbreviations prohibited by the Joint Commission are deleted. The abbreviation “QD” is one of those.

  8. john loertscher says:

    right on the money TAP!
    All e-prescribing is doing is substituting one error for another. It isn’t just the sigs that are getting screwed up by the faulty ‘drag and clicking’ but the wrong drugs and strengths. Obviously Levaquin was qd and not qid. But it isn’t so obvious an error when some Delbert selects Diovan 320 when they MEANT to select 160
    Of course, this means that we end up calling on damn near every dose change that is sent to us for this precise reason.
    Keep the faith TAP!

  9. Google Account says:

    The pharmacy I work at(it’s part of an HMO that starts w/ K…) uses eRx all the time. The doctor does his prescribing and puts a priority on it (not too sure how the doctor decides on the priority, but I think it might depend on how soon the pt is going to pick up the meds). If it is high priority, then the technician or intern types it up. If it is medium/low priority, only the pharmacist can pull type it up. I guess the software ppl put that in as a safeguard?
    Usually, the pharmacist has been able to pick out the mistakes on the eRx and has to call back the doctor. I totally agree with you that if the pharmacist is not at their 100% then they might miss the mistakes.
    From my limited experience as an intern at this pharmacy, I think the eRx helps a lot since it allows us to transfer the prescriptions among the different pharmacies in our “chain” and it helps a lot when for some reason we happens to misplaces the hard copy. (We don’t scan the Rxs and there were times when we misplace the hard copy with 20+ Rxs on the filling line and we need to print out a new hard copy of eRx). Also it saves us a lot of time if we didn’t have to figure out the handwriting for all the 800+ prescriptions we’re filling everyday.
    btw, lol on the dentist not knowing what the mistake on the Levaquin rx was.

  10. rph3664 says:

    Amber, if the doctor you mentioned was an orthopedic surgeon, I would think you were talking about one who lived here.
    I recently got an order from him at 11pm that said “Vancomycin IV daily q12h.” Huh? I entered a one-time dose and left it for the morning pharmacist to deal with rotfl.

  11. springpharm says:

    Something I’ve learned in my (ooh ahh) 2 years of practice is to read back to the person on call-ins and transfers, then write on the rx that you read it back to them, of course get their name, and you shouldn’t have anything to worry about! (Unless the person doesn’t speak Engrish (haha) and then just follow TAP’s lead and call them out on it!)
    one comment on e-prescribe…
    The nurses drive you nuts when they tell the person standing at your counter (on their cell phone) that they’ve already sent the e-prescribe, which they haven’t and then hurry and send it right then, making you RUSH b/c the asshole at the counter already thought it should be ready when they walked in and now they’re really in a hurry for it!!!!!!!!!
    AHHHHHHHHHHH!!!!

  12. http://openid.aol.com/tamzidy says:

    as for prescriptive authority, even midwives can fucking write presriptions…even for pain killers with a valid dea #! what the hell, we’re all stoodges

  13. Linda says:

    I hate it when people say or write “doctors and dentists”…Dentists are doctors. It should say physicians and dentists..thanks

  14. Google Account says:

    TAP–right on the money, as always. I am with a small home health agency, (I know, your favorites!!) and you will be glad to know that we have ZERO–that’s right-NOT A SINGLE- foreign nurses, and never will. All of our RN’s speak, read, and write English, and actually know the diff between Xanax and Zantac. BTW…most of our older patients ARE truly morons! We get the bag at home filled with Lasix and furosemide right after the hospital stay for syncopal episodes.

  15. MikeRx says:

    Had call-in Rx’s today for Clonazepam 5 mg and diphenhydramine 20mg (which turned out to be dicyclomine 20mg)from a wonderful “assistant” on the answering machine and an eprescription for toprol xl 200mg 1 tablet AM and 1.5 mg. #75 from the same office. (yeah read that again) Its obvious what the prescriber meant, but its not what he wrote. Best part is that the office will not accept pharmacy calls because of high call volume. Wonder if the high call volume is due to the repeated fuck ups like those listed above.

  16. Google Account says:

    My favorite is when you get a phone in on the message line, then call back to clarify…
    Me: “did you really mean warfarin 20 mg? because that is a huge dose and she was on 2 mg last week…”
    Her: “well, that’s what it says here”
    Did I ask what it said there? I’m obviously calling because it seems off. Maybe you wanna go ask????

  17. Toc says:

    I am so happy that I found your blog, accidentally! Well~ from Google search result actually. I have a question for you: is it true that is hard to find a job for a certified pharmacy technician? Plus the bad economy now…

  18. JJK says:

    There is a clinic across the street from us and one down the hall in our strip mall. They both send e-scripts, which we aren’t set up to receive yet, so they come in as a fax. People will come straight over after leaving the doctor expecting the scripts to be done (10 minutes after the MD pushed send). Never mind that I haven’t even had time to so much as look at the fax machine in the last 20 minutes. In fact, thanks to the wonders of modern technology, people coming from down the hall frequently beat the fax into the pharmacy. The doctors, of course, require 24 to 48 hours to respond to a fax request from us.

  19. Ray Poorbaugh says:

    TAP do you have any idea how true this is? Have you experienced something like this…
    “They will just show on the chart it was written correctly, taken verbally by Pharmacist-X and that’ll be the end of their accountability. Pretty sad to know that your career/livelihood is being held by some idiot who cant point to where her rectum is.”
    I have. Here is the story:
    As an intern worked at a pharmacy that did part time nursing home fills, maybe 2% of our total volume. However, it was about 80% of our problem prescriptions that needed clarification etc.
    Well often times orders would be written after 12noon and the nurse would verbal them to us in order to get them in the afternoon delivery. The next morning the faxed chart would come down and often times the med sent or directions were not verbaled correctly (or were changed we aren’t sure). The order would be reentered and a new card of med would be sent. This entire time (unbeknownst to us) they were charting and documenting this as a “pharmacy med error”.
    So, finally a patient/p.o.a or whatever called the board of pharmacy on the nursing home and they sent in a swat team of investigators. They found these “pharmacy med errors” and charged me and the pharmacist/owner for 25 counts of unprofessional conduct/misbranding of medication. At the hearing our copies of the verbals were worthless. They had the charts and the orders and them med error reports, that was all the proof they needed. It cost me 250 dollars (thank god I was an intern) and the pharmacist 25,000 dollars (1000 per offense) and license not in good standing for 3 years. I had to get a new job because he couldn’t precept me anymore.
    Our rears are in the meatgrinder no matter what on this…I hate phone in/e-rx/faxing forever for this reason alone.

  20. Tim says:

    Seems to me the remedy to the eRx is simple: Don’t have drop down menus.

  21. KDUBZ says:

    I personally hate when I call and talk to a medical assistant because the brilliant physician wrote for something with a serious interaction, and they respond “Oh yeah thats fine.” Great the medical assistant has the ability to manage interactions now.
    DAMN YOU APhA, get us prescriptive authority you worthless organization of jag bags! I’m sorry but managing simple conditions is something a pharmacist can do, especially if a medical assistant is able to ok dispense something with a serious interaction!
    I also see someone pissed off a dentist, nice. If you have ever seen the move “The Dentist” you would learn to avoid doing so!

  22. Becka says:

    As a nationally certified pharmacy tech who is allowed to take new, called in prescriptions over the phone, I think it’s fine for us to do that. I also take scripts off voicemail, and if I can’t get what’s being said after replaying, I have the pharmacist listen. I think actual calls are better, because I can ask the person on the other end of the phone any questions. I have caught mistakes numerous times, and the person ends up hanging up to go check with the doctor. I’m sure I’ve not caught everything, but I’m smart enough to know Levaquin wouldn’t be QID, and I would have questioned that if someone called it in to me.

  23. B Haze says:

    No, technicians should never pick up a script pad. Never. They wouldn’t touch one with my license hanging on the wall.

  24. jrx says:

    Whoa, TAP. I hope you have a field day with “Becka” the Nationally Certified Tech.

  25. pharmd says:

    Sorry to say becka that if you dont have a pharmacist license you cannot be taking rx’s over the phone or called in…It’s the law and btw if u make a mistake it’s our license.

  26. ADHD CPhT says:

    Ok, a little off topic here, but since when in the fuck are techs able to take new scripts over the phone? I’ve been certified for 5+ years, and have been working in pharmacy as a non-certified tech longer. I could probably do it, but not only do I not want to, but I could damage a pharmacist’s livelihood by fucking up tremendously.
    In my state, it’s not required for pharmacy technicians to be certified OR ‘licensed’ (whatever that does), so I wonder if that’s a factor, but what the shit? I technically can’t take refills over the phone. Since when does passing an easy as fuck test qualify me to interpert a doctor’s verbal orders?
    That doesn’t seem right.

  27. Crusty RPh says:

    E-prescribing my ass. These fuckers are charging us 25cents a piece to send them to us. With a professonal fee of $1.50, that is another 16 2/3 % off our profit. Let me see, 25 to 75 cents for the bottle 5 cents for the label and 25 cents for the E-Script, that leaves 45 to 95 cents for the pharmacy. That has to cover rent,utilities, labor and profit.

  28. tartnoir says:

    In some states it is indeed legal for certified pharmacy techs to take scripts over the phone. One example is Massachusetts, where certified techs can take oral scripts as long as the pharmacist on duty approves.
    If you can’t believe it, read the following documents:
    http://www.mass.gov/Eeohhs2/docs/dph/quality/boards/pharmacy_technician_faq.pdf (for tech FAQ’s – duty list at the end of the document)
    http://www.mass.gov/Eeohhs2/docs/dph/regs/247cmr008.pdf (for the MA Board of Pharmacy Rules and Regulations regarding pharmacy interns and techs).
    There is state registration of technicians in Vermont, New Hampshire, Connecticut and Massachusetts, but not New York or Pennsylvania as of now. I don’t know about Rhode Island or Maine.

  29. tech holdin on a tec says:

    one problem with escribes is they allow for a prescriber to send a patient to believe that as soon as there doc hits enter we at the pharmacy will have their med ready right then.they (md’s) dont know our work load. they dont know if we have the patients insurance info. what if we dont happen to have the meds in stock. then we Have to call other pharmacies to see if they have the meds. which delays the other e-rx’s that theses doc;s send. nit to mention when an asshole doc sends an e-rx for freakin Guaifenesin. is it thats damn hard to tell a patient to go buy robitussin. they are sitting in our lobby with a dear in the headlights look on their face , wondering why we still havent filled their rx. i need a fiorcet

  30. chilihead says:

    With the economy the way it is, the news keeps saying that employers are being picky about the applicants. They pick and choose to get good employees at a lower price, allegedly, because right now they can afford to do so, according to reports.
    It seems that many employers are doing the opposite, however. From Home Depot to certain medical offices, they seem to have fired their best employees and took on idiots. According to some sources, they do this because they are afraid that as soon as the economy turns around, the good ones will leave. It’s the stupidest excuse I’ve ever seen, but I’ve known employers with this mindset and they wonder why their business suffers in the long term (recent example – Circuit City… got rid of their best about a year or so ago, and look at them now).
    There comes a point, experience has to start somewhere. I also understand why they want experienced employees. Yet they have these flaky idiots on staff who will not speak clearly on the phone, learn English, and learn their medical terminology.
    Reading rants like this article, I have come to believe that I have wasted my time studying and should have just gone on welfare and acted like some stupid piece of trailer park trash. That way, I could get welfare-to-work assistance perhaps getting a job in a medical office!

  31. ADHD CPhT says:

    Ok, I believe you guys about techs legally taking verbal Rxs over the phone in some states…but at the same time, I *can’t* believe it. I am dumbfounded that it’s freaking ok for us to do that period, ANYWHERE.
    What pharmacist in his/her right mind would allow that to take place under their license?
    Also, do these particular states mandate a specific educational program for these techs in addition to the CPT exam? If not, then that’s a travesty.

  32. Richard says:

    Just a comment on pharmacy software – I’m one of the software engineers (FWIW, there’s more to software engineering than just programming) that you spoke of that has never spent much time at a pharmacy.
    But it’s irrelevant. Our job is to produce software that conforms to specification. Who creates the specifications? Pharmacists and pharmacy technicians who decided they don’t enjoy being behind the counter and would rather work as a subject matter expert in a software company. They work with software designers to specify exactly how the software should work and look at feel. Trust me, you wouldn’t want software written by a software engineer that was trying to play double-duty developing software and understanding pharmaceuticals any more than you would want a pharmacist that also doubles as a realtor filling your prescriptions. It’s a complex profession and it’s dangerous for everyone involved to spread yourself too thin.
    So, while I’m not familiar with the particular software you mentioned, the design flaws you mentioned are caused by pharmacists and techs who are not well suited for the software business. Either they are incompetent, or they are just being pushed too hard for unrealistic deadlines by directors who care more about getting their fucking end of year bonuses than they are about human lives. The latter problem is common to all software development scenarios and not just pharmacy software.

  33. (1) The fact the a physician (happy dentist???) can designate ANYONE, including the crack-smoking janitor, to call in scripts is fucking ludicrous.
    (2) Don’t even get me started on all the lazy, uneducated, incompetent twats who work in doctor’s offices as receptionists who like to call themselves nurses because they get to wear scrubs. I imagine this really pisses off real nurses, you know, the kind that went to nursing school and break their asses working in hospitals???
    (3) Yesterdays call-in…..Ambien 10mg, one every 6 hours. Maybe if I took my ambien that way, I wouldn’t hate my fucking job so much. Keep on ranting, TAP, you make my day.

  34. mdcnmn says:

    In the state of TN a CPht can take new rxs, it all depends on your state pharmacy laws. I am not cool with that. I work in AL and they are not even allowed to add refills to rxs that we have called on and are waiting for the MD to call back on. What bugs me the most is that when I pick up the phone to check the message system or talk to a MD’s office and the numb nuts on the other side is the guy who changes out the garbage and stutters, has a cleff palate, a lisp, plus only speaks 3 words of english but since he works in the office he can call in rxs its ok. My god what are we doing here ordering sub sandwiches or dealing with peoples lives. Another thing the rx printing system these MDs use, they need to learn how to proof read before they send the out. “Lasix liq, 1 po qd, #30” does not make sense. Either slow down and read it over before you sign your name to it or write in out yourself.

  35. Tyler says:

    I agree with all of the above, but you do have to give some technicians credit. I’ve seen technicians miss and catch eRx mistakes and get them resolved before they ever make it to the pharmacist. I believe educating technicians so they know the difference is key in preventing errors that are missed by the pharmacist making it to the patients.
    On the whole call in from uneducated dumbasses, you’re right! I myself have been part in many arguments with MD offices about the serious implications that could occur from a dumbass calling in medications. With that being said, most offices in my area of the woods have the MD’s call it in themselves. It doesn’t hurt to prove the point when a office assistant calls in a prescription of Dilantin like this…
    Dilantin 100mg
    Take one tablet by mouth Mon, Wed, Fri
    and take one-half tablet by mouth tues and thurs.
    Hello!!!! Dumbasses.. How the fuck are you going to cut a “Kapsule” in half? You’re a stupid stupid person and the MD’s that hired you are stupid themselves. Call it in as 100mg and 50mg… We can’t do crap when you call it in this way..!
    Should should have to atleast goto a 2 year school for this. How to read and know your head from ass.

  36. Beth in TX says:

    TAP,
    I think I love you. That is all.
    Beth
    Hospital pharmacy technician for the past 6 years.

  37. Mimmy says:

    You’re gonna love this.
    Left on voicemail the other day: “Singulair 4 mg, 1 every hour sleep?”
    That is exactly what she said. Plus, you could tell from the tone of her voice that she had NO idea what she was talking about.
    So the pharmacist called her back to clarify the directions, and she repeated the same damn thing. Finally he just asked her to read it out as it was written. 1 QHS? Thank you! Click.

  38. Anon says:

    For your levaquin example, I’m a pharm tech (that doesn’t know better), and would have filled it just like it said.
    It’s not until I just read up on Levaquin did I realize its toxicity factor.
    That’s scary something like that could happen.

  39. Kevin CPhT says:

    SO Im a CPht in AR. and I cannot legally take phone scripts in my state. I can however do it if needed, In Arkansas the idea of allowing Certified techs to take phone scripts has been bouncing around for a while. See If a nurse calls in an Rx for a zpak and doesn’t know the directions, ( which happened allot) why cant I take that down? I and every one else on this site know how to dispense it. If they call in lithium 300mg caps and say qid… Im going ask if its qid or qd. if they call and want metformin 500er qid well again I know that sounds off. If I miss something then the RPh is there to catch the mistakes. and If im unsure I always ask. While Many Techs are dumb asses I wouldn’t trust to clean my bathroom, some and most importantly the ones who are certified, I feel are just fine taking phone scritps. after all many techs are future pharmacists.

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