Joint Commission journal on quality and patient safety最新文献

{"title":"Frontline Providers’ and Patients’ Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study","authors":"Courtney W. Mangus MD (is Clinical Assistant Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan.),&nbsp;Tyler G. James PhD (is Assistant Professor, Department of Family Medicine, University of Michigan.),&nbsp;Sarah J. Parker MPH (is Research Area Specialist, Department of Emergency Medicine, University of Michigan.),&nbsp;Elizabeth Duffy MPH (is Clinical Research Coordinator, Department of Emergency Medicine, University of Michigan.),&nbsp;P. Paul Chandanabhumma PhD, MPH (is Assistant Professor, Department of Family Medicine, University of Michigan.),&nbsp;Caitlin M. Cassady LMSW, LCSW (is PhD Candidate, Social Work and Anthropology Doctoral Program, Wayne State University.),&nbsp;Fernanda Bellolio MD, MS (is Emergency Medicine Physician and Health Sciences Researcher, Departments of Emergency Medicine and Health Science Research, Mayo Clinic, Rochester, Minnesota.),&nbsp;Kalyan S. Pasupathy PhD (is Professor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago.),&nbsp;Milisa Manojlovich PhD, RN (is Professor, Department of Systems, Populations and Leadership, School of Nursing, University of Michigan.),&nbsp;Hardeep Singh MD, MPH (is Professor, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA (US Department of Veterans Affairs) Medical Center and Baylor College of Medicine, Houston.),&nbsp;Prashant Mahajan MD, MBA, MPH (is Professor, Departments of Emergency Medicine and Pediatrics, University of Michigan. Please address correspondence to Courtney W. Mangus)","doi":"10.1016/j.jcjq.2024.03.003","DOIUrl":"10.1016/j.jcjq.2024.03.003","url":null,"abstract":"<div><h3>Background</h3><p>Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety.</p></div><div><h3>Methods</h3><p>Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED–Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews.</p></div><div><h3>Results</h3><p>The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED–Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused.</p></div><div><h3>Conclusion</h3><p>Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 480-491"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140280474","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Putting the “Action” in RCA2: An Analysis of Intervention Strength After Adverse Events","authors":"Jessica A. Zerillo MD, MPH (is Senior Medical Director of Patient Safety, Beth Israel Deaconess Medical Center, and Assistant Professor of Medicine, Harvard Medical School, Boston.),&nbsp;Sarah A. Tardiff BSN, RN (is Senior Project Manager of Patient Safety, Beth Israel Deaconess Medical Center.),&nbsp;Dorothy Flood BSN, RN (is Director, Patient Safety/Health Care Quality, Beth Israel Deaconess Medical Center.),&nbsp;Lauge Sokol-Hessner MD, CPPS (is Associate Professor of Medicine, University of Washington (UW), and QI Mentor, UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle.),&nbsp;Anthony Weiss MD, MBA (is Chief Medical Officer, Beth Israel Deaconess Medical Center, and Associate Professor of Psychiatry Harvard Medical School. Please address correspondence to Jessica A. Zerillo)","doi":"10.1016/j.jcjq.2024.03.012","DOIUrl":"10.1016/j.jcjq.2024.03.012","url":null,"abstract":"<div><h3>Background</h3><p>Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed.</p></div><div><h3>Methods</h3><p>Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023. The authors retrospectively coded corrective actions by category and strength using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool.</p></div><div><h3>Results</h3><p>In the analysis of 67 events, 15 contributing factor themes were identified and resulted in 148 corrective actions. Of these events, 85.1% (57/67) had more than one corrective action. Of the 148 corrective actions, 84 (56.8%) were rated as weak, 36 (24.3%) as intermediate, 15 (10.1%) strong, and 13 (8.8%) needed more information. The completion rate was 97.6% (for weak corrective actions), 80.6% (intermediate), and 73.3% (strong) (<em>p</em> &lt; 0.0001).</p></div><div><h3>Conclusion</h3><p>Safety events were often addressed with multiple corrective actions. There was an inverse relationship between intervention strength and completion, the strongest interventions with the lowest rate of completion. By integrating action strength and completion status into corrective action follow-up, health care organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 492-499"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140870150","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Challenge of Improving Patient Safety: This is Hard","authors":"Robin R. Hemphill MD, MPH (is Chief of Staff, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio. Please address correspondence to Robin Hemphill)","doi":"10.1016/j.jcjq.2024.05.001","DOIUrl":"10.1016/j.jcjq.2024.05.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 478-479"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140921353","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Simple Risk Adjustment for Hospital-Level Nulliparous, Term, Singleton, Vertex, Cesarean Delivery Rates and Its Implications for Public Reporting","authors":"Benjamin D. Pollock PhD, MSPH (is Assistant Professor of Health Services Research and Senior Associate Consultant II–Research, Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida.),&nbsp;Leslie Carranza MD (is Quality Chair, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota.),&nbsp;Elizabeth Braswell-Pickering MPH (is Senior Quality Informatics Analyst, Mayo Clinic, Rochester, Minnesota.),&nbsp;Christine M. Sing DPT, MBA (is Operations Manager, Quality & Value, Mayo Clinic, Rochester, Minnesota.),&nbsp;Lindsay L. Warner MD (is Anesthesiologist and Pediatric Anesthesiologist, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.),&nbsp;Regan N. Theiler MD, PHD (is Associate Professor, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota. Please address correspondence to Benjamin D. Pollock)","doi":"10.1016/j.jcjq.2024.04.006","DOIUrl":"10.1016/j.jcjq.2024.04.006","url":null,"abstract":"<div><h3>Background</h3><p>The Joint Commission uses nulliparous, term, singleton, vertex, cesarean delivery (NTSV-CD) rates to assess hospitals’ perinatal care quality through the Cesarean Birth measurement (PC-02). However, these rates are not risk-adjusted for maternal health factors, putting this measure at odds with the risk adjustment paradigm of most publicly reported hospital quality measures. Here, the authors tested whether risk adjustment for readily documented maternal risk factors affected hospital-level NTSV-CD rates in a large health system.</p></div><div><h3>Methods</h3><p>Included were all consecutive NTSV pregnancies from January 2019 to April 2023 across 10 hospitals in one health system. Logistic regression, adjusting for age, obesity, diabetes, and hypertensive disorders. was used to calculate hospital-level risk-adjusted NTSV-CD rates by multiplying observed vs. expected ratios for each hospital by the systemwide unadjusted NTSV-CD rate. The authors calculated intrahospital risk differences between unadjusted and risk-adjusted rates and calculated the percentage of hospitals qualifying for different reporting status after risk adjustment using the 30% Joint Commission reporting threshold rate.</p></div><div><h3>Results</h3><p>Of 23,866 pregnancies, 6,550 (27.4%) had cesarean deliveries. Across 10 hospitals, the number of deliveries ranged from 393 to 7,671, with unadjusted NTSV-CD rates ranging from 21.0% to 30.5%. Risk-adjusted NTSV-CD rates ranged from 21.5% to 30.4%, with absolute intrahospital differences in risk-adjusted vs. unadjusted rates ranging from −1.33% (indicating lower rate after risk adjustment) to 3.37% (indicating higher rate after risk adjustment). Three of 10 (30.0%) hospitals qualified for different reporting statuses after risk adjustment.</p></div><div><h3>Conclusion</h3><p>Risk adjustment for age, obesity, diabetes, and hypertensive disorders is feasible and resulted in meaningful changes in hospital-level NTSV-CD rates with potentially impactful consequences for hospitals near The Joint Commission reporting threshold.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 500-506"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140780264","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Quest for Diagnostic Excellence in the Emergency Department","authors":"Michael S. Pulia MD, PhD (is Associate Professor, Departments of Emergency Medicine and Industrial and Systems Engineering University of Wisconsin-Madison.),&nbsp;Dimitrios Papanagnou MD, MPH (is Professor, Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia.),&nbsp;Pat Croskerry MD, PhD (is Professor, Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. Please address correspondence to Michael S. Pulia)","doi":"10.1016/j.jcjq.2024.05.004","DOIUrl":"10.1016/j.jcjq.2024.05.004","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 475-477"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141035737","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Communication After Medical Error: The Need to Measure the Patient Experience","authors":"Allen Kachalia MD, JD (is Senior Vice President, Patient Safety and Quality, and Director, Director, Armstrong Institute of Patient Safety and Quality; and Professor of Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore.),&nbsp;Carole Hemmelgarn MS, MS (is Program Director, Executive Master's Clinical Quality, Safety and Leadership, Georgetown University, and Senior Director Education, MedStar Health, Washington, DC.),&nbsp;Thomas H. Gallagher MD, MACP (is Executive Director, Collaborative for Accountability and Improvement, and Associate Chair of Medicine for Patient Care, Quality, Safety, and Value, UW Medicine, Seattle; and Professor of Medicine and Professor of Bioethics & Humanities, University of Washington. Please address correspondence to Allen Kachalia)","doi":"10.1016/j.jcjq.2024.06.006","DOIUrl":"10.1016/j.jcjq.2024.06.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 9","pages":"Pages 618-619"},"PeriodicalIF":2.3,"publicationDate":"2024-06-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141626824","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter to the Editor on “Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery”","authors":"Margaret V. Darko BA (is a Medical Student, Weill Cornell Medical College, NewYork-Presbyterian/Weill Cornell Medical Center, New York.),&nbsp;Robert White MD, MS (is an Anesthesiologist, Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center.),&nbsp;Deirdre C. Kelleher MD (is an Anesthesiologist, Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center. Please address correspondence to Margaret V. Darko)","doi":"10.1016/j.jcjq.2024.06.005","DOIUrl":"10.1016/j.jcjq.2024.06.005","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 10","pages":"Pages 748-749"},"PeriodicalIF":2.3,"publicationDate":"2024-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141734153","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Will Ambulatory Safety Nets Go Viral?","authors":"Lawrence Lurvey MD,JD (is Obstetrician/Gynecologist, Southern California Permanente Medical Group, Los Angeles.),&nbsp;Lyn Yasumura MD (is a Principal Consultant for Summitbridge Health Solutions LLC.),&nbsp;Elena Martinez MD (is Obstetrician/Gynecologist, Southern California Permanente Medical Group. Please address correspondence to Lawrence Lurvey)","doi":"10.1016/j.jcjq.2024.06.004","DOIUrl":"10.1016/j.jcjq.2024.06.004","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 10","pages":"Pages 687-689"},"PeriodicalIF":2.3,"publicationDate":"2024-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141734154","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing Inappropriate Stat Echocardiograms: A Quality Improvement Initiative (RISE-QI)","authors":"","doi":"10.1016/j.jcjq.2024.06.001","DOIUrl":"10.1016/j.jcjq.2024.06.001","url":null,"abstract":"<div><h3>Background</h3><div><span>A complete transthoracic echocardiogram takes approximately 45 minutes to complete, including time for image acquisition and preliminary reporting by the </span>sonographer. The process can take substantially longer if there are technical difficulties or if contrast must be administered due to suboptimal imaging windows. This can create a considerable echocardiogram backlog at high-volume institutions. At the authors’ institution, there was a concern that ordering providers were inappropriately designating studies as stat to get their patients to the front of the bottleneck. On review, the quality improvement team found that 19.9% of all echocardiograms ordered during June 2021 were designated stat, of which 44.0% contained indications that the team determined were rarely appropriate for a stat priority designation.</div></div><div><h3>Methods</h3><div>The team located a flaw in the electronic health record interface that encouraged overuse of the stat designation, so an interface change was designed and implemented to create a hard stop requiring the selection of predetermined indications for any stat order. We also reduced the number of steps required to select the less-urgent ASAP priority to encourage its use over stat priority.</div></div><div><h3>Results</h3><div>Within one month postintervention, there was a statistically significant 36.3% reduction in the order of stat echocardiograms, with a concurrent 173.9% rise in ASAP orders over the same time frame. These numbers remained steady at one-year and two-year follow-up analyses.</div></div><div><h3>Conclusion</h3><div>A quick and simple modification to the echocardiogram order user interface can lead to a considerable reduction in the number of stat orders.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 10","pages":"Pages 719-723"},"PeriodicalIF":2.3,"publicationDate":"2024-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141393098","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Going (Anti)Viral: Improving HIV and HCV Screening and HPV Vaccination in Primary Care","authors":"","doi":"10.1016/j.jcjq.2024.06.002","DOIUrl":"10.1016/j.jcjq.2024.06.002","url":null,"abstract":"<div><h3>Background</h3><p><span>Human immunodeficiency virus (HIV) and hepatitis C (HCV) screening and human papillomavirus (HPV) vaccine uptake remain suboptimal. To improve HIV and HCV<span> screening and HPV </span></span>vaccination<span>, the authors implemented a quality improvement project in three southwestern Pennsylvania family medicine residency practices.</span></p></div><div><h3>Methods</h3><p><span>From June 1 to November 30, 2021, participating practices used universal screening and vaccination guidelines and chose from multiple strategies at the office (for example, standing orders), provider (for example, multiple forms of provider reminders), and patient (for example, incentives) levels derived from published literature and tailored to local context. Age-eligible patients for each recommendation with at least one in-person office visit during the intervention period were included. To assess the interventions’ effect, the authors obtained testing and vaccination data from the electronic health record for the intervention period, contrasted it with identical data from June 1 to November 30, 2020, and used </span>logistic regression controlling for patient age, sex, and race to determine differences in screening and vaccination between intervention and baseline periods.</p></div><div><h3>Results</h3><p>A total of 14,920 and 15,523 patients were eligible in the baseline and intervention periods, respectively. Following the intervention, HIV lifetime screening but not first-time screening for patients 13–64 years old was significantly higher (78.9% vs. 76.1%, <em>p</em> = 0.004, and 39.6% vs. 36.6%, <em>p</em><span> = 0.152, respectively, adjusted odds ratio [aOR] 1.21, 95% confidence interval [CI] 1.06–1.38). HCV lifetime screening for patients 18–79 years old was significantly higher postintervention (62.5% vs. 53.5%, </span><em>p</em><span> &lt; 0.001, aOR 1.51, 95% CI 1.4–1.64). For patients 9–26 years old, no change in HPV initiation was observed, but the percentage of patients who completed their HPV vaccinations in the observed period was significantly higher postintervention (7.0% vs 4.6%, </span><em>p</em> = 0.006, aOR 1.58, 95% CI 1.14–2.2). During the postintervention period, the researchers identified 0 new HIV diagnoses and 48 HCV diagnoses (19 eligible for treatment).</p></div><div><h3>Conclusion</h3><p>Family medicine residency office-based multistrategy efforts appear to successfully increase patient uptake of HIV and HCV screenings and maintain HPV vaccination rates.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 9","pages":"Pages 645-654"},"PeriodicalIF":2.3,"publicationDate":"2024-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141413630","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}