Context Despite the best efforts of health care practitioners, medical errors
are inevitable. Disclosure of errors to patients is desired by patients and
recommended by ethicists and professional organizations, but little is known
about how patients and physicians think medical errors should be discussed.
Objective To determine patients' and physicians' attitudes about error disclosure.
Design, Setting, and Participants Thirteen focus groups were organized, including 6 groups of adult patients,
4 groups of academic and community physicians, and 3 groups of both physicians
and patients. A total of 52 patients and 46 physicians participated.
Main Outcome Measures Qualitative analysis of focus group transcripts to determine the attitudes
of patients and physicians about medical error disclosure; whether physicians
disclose the information patients desire; and patients' and physicians' emotional
needs when an error occurs and whether these needs are met.
Results Both patients and physicians had unmet needs following errors. Patients
wanted disclosure of all harmful errors and sought information about what
happened, why the error happened, how the error's consequences will be mitigated,
and how recurrences will be prevented. Physicians agreed that harmful errors
should be disclosed but "choose their words carefully" when telling patients
about errors. Although physicians disclosed the adverse event, they often
avoided stating that an error occurred, why the error happened, or how recurrences
would be prevented. Patients also desired emotional support from physicians
following errors, including an apology. However, physicians worried that an
apology might create legal liability. Physicians were also upset when errors
happen but were unsure where to seek emotional support.
Conclusions Physicians may not be providing the information or emotional support
that patients seek following harmful medical errors. Physicians should strive
to meet patients' desires for an apology and for information on the nature,
cause, and prevention of errors. Institutions should also address the emotional
needs of practitioners who are involved in medical errors.
Health care institutions nationwide are developing ambitious programs
to prevent medical errors.1,2 Yet,
despite our best efforts, medical errors will inevitably occur.3 An
important component of the response to an error is deciding whether and how
to tell the patient about what happened. Disclosing medical errors respects
patient autonomy and truth-telling, is desired by patients, and has been endorsed
by multiple ethicists and professional organizations.4-19 In
addition, hospital accreditation standards and some state laws now require
that patients be informed about "unanticipated outcomes" in their care.20-23
The limited available data, however, suggest that full disclosure of
errors to patients may be uncommon. In a 1991 study, 76% of house officers
said they had not disclosed a serious error to a patient.24 Multiple
factors may inhibit physicians from disclosing errors, such as fear that informing
the patient of an error could lead to a malpractice suit, damage the physician's
reputation, and be awkward and uncomfortable.15,25-31 Some
institutions are developing new policies requiring or strongly encouraging
disclosure of some errors to patients.7,32-37 It
is not known whether these policies are increasing error disclosure. In a
recent national survey, only 30% of respondents who experienced a medical
error said that the involved health care professional had informed them of
the error.12 Failure to tell patients about
medical errors could impair patient trust and satisfaction and increase the
chances of a malpractice suit.13-15,26,38-43
Greater insight into patients' and physicians' attitudes toward error
disclosure could improve the way institutions and practitioners handle these
prior studies have examined either patients' or physicians' general attitudes
about medical errors in isolation.13,15,16,24,29,49-51 Yet,
an important element of the response to a medical error is the interaction
between the patient who experienced the error and that patient's physician.
Therefore, strategies for responding to medical errors should simultaneously
consider the attitudes of physicians and patients about errors and their disclosure.12,15,52 To better understand
this issue, we conducted a series of 13 focus groups, including 3 joint patient-physician
focus groups. Our specific research questions were (1) What are the attitudes
of patients and physicians about medical error disclosure? (2) Do physicians
disclose the information patients desire about medical errors? (3) What are
patients' and physicians' emotional needs when an error occurs, and are these
needs being met?
We conducted 13 focus groups in St Louis, Mo, between April and June
2002. Six groups involved patients, 4 groups involved physicians, and 3 groups
included both patients and physicians. The focus groups had an average of
10 participants per group (range, 7-13). The goals of the patient-only and
physician-only focus groups were to obtain a baseline understanding of each
group's attitudes about error disclosure and to discuss topics that patients
and physicians might hesitate to share in front of the other party. The goal
of the joint focus groups was to create a patient-physician dialogue about
error disclosure to better understand these 2 perspectives. The Washington
University Medical Center Human Studies Committee approved the study, and
all participants provided written informed consent.
We recruited patient participants using newspaper advertisements and
flyers. Patients were eligible to participate if they were older than 18 years,
able to provide written informed consent, and active users of health care,
defined by hospitalization in the last 2 years, having a chronic illness,
or having a regular source of health care. A total of 52 patients participated.
Patient participants were predominantly female (71%) and white (88%) and were
a mean age of 60 years (Table 1).
Physician participants were recruited through direct mailings to primary
care physicians and surgeons practicing in the St Louis area. A total of 46
academic and community physicians participated in the focus groups. Physicians
were predominantly male (83%) and white (78%) and had been in practice for
an average of 16 years (Table 1).
The most common specialties were surgery (54%) and internal medicine (33%).
The participants for the 3 joint patient-physician focus groups were
drawn from individuals in the patient-only and physician-only focus groups.
Approximately equal numbers of patients and physicians participated in each
joint focus group.
Conducting the Focus Groups
All focus groups were led using detailed guides (available from the
authors on request). A psychologist (A.D.W.) led the patient-only focus groups,
while a physician (T.H.G.) led the physician-only groups. The joint patient-physician
focus groups were co-led by both moderators. Standard moderation techniques
were used throughout.53-55 All
focus groups lasted 90 minutes and were audiotaped.
The patient-only focus groups began by discussing what the terms patient safety and medical errors meant
to participants. Definitions of medical errors and adverse events developed
by the Federal Quality Interagency Coordination Task Force were then presented.
An error was defined as "failure of a planned action to be completed as intended
or the use of a wrong plan to achieve an aim." An adverse event was defined
as an "injury that was caused by medical management and resulted in measurable
A hypothetical situation involving a medication error was then presented
to participants. Patients were asked to imagine they were a patient with diabetes
admitted to the hospital with breathing problems. They receive a 10-fold overdose
of insulin, due in part to a physician's handwritten order for "10 U" of insulin
being misinterpreted to read "100 units." As a result of this overdose, the
patient becomes severely hypoglycemic, loses consciousness, is resuscitated,
and is transferred to the intensive care unit. The patient recovers uneventfully
and incurs no permanent harm. Patients were asked to consider whether and
how they would want this error disclosed to them and what else should be done
in response to this error. Variations of the error were then presented, including
a near-miss situation in which the nurse catches the error before administering
the insulin. Participants also volunteered personal examples of medical errors
and how they had been handled.
The physician-only focus groups followed a similar format. Definitions
of medical errors and adverse events were presented, followed by a discussion
of whether and how medical errors should be disclosed to patients. Physicians
then discussed what they would disclose to the patient in the insulin overdose
scenario. In addition, physicians discussed a second scenario that a participant
in the first physician focus group presented. In this second scenario, physicians
have ordered a medication known to raise potassium. They order a potassium
blood test for the following day but forget to check the results. On the third
hospital day, the patient develops hyperkalemic arrhythmias. Reviewing the
laboratory results they overlooked from the previous day, the physicians realize
the potassium had risen substantially from admission. Had they seen this elevated
potassium level 1 day earlier, they would have stopped the new medication
and treated the patient's hyperkalemia. Participants discussed whether and
how this second error should be disclosed to the patient. The groups concluded
with physicians sharing personal experiences of error disclosure.
The joint patient-physician focus groups started using a "circle within
a circle" approach, in which patients sat in an inner circle with physicians
listening in an outer circle. The patients talked with each other about medical
errors and why they happen. Physicians then moved into the inner circle while
patients listened in the outer circle. Physicians commented on what they had
heard the patients say and then talked among themselves about the experience
of making errors and discussing errors with patients. The remainder of the
joint focus group took place with all participants in a common circle and
focused on the optimal resolution of medical errors from both participants'
Analyzing the Focus Groups
The focus group audiotapes were transcribed verbatim and reviewed by
3 investigators (T.H.G., A.D.W., and A.G.E.) to identify major themes. Two
investigators (A.D.W. and A.G.E.) then reread each transcript, manually coding
the presence of each theme as well as identifying quotations exemplifying
these themes. Any differences of opinion about the meaning of specific passages
in the transcripts were discussed and resolved. Only the themes that recurred
in each of the relevant focus groups are presented herein.
Although patients' and physicians' attitudes about medical errors and
their disclosure had much in common, important differences existed between
the perspectives of these 2 groups (Table
Patients' and Physicians' General Attitudes About Medical Errors
All patients were aware of the topic of errors in medicine, either through
firsthand experience or from recent media stories. Patients conceived of medical
errors broadly. Despite being presented a standard definition of medical errors,
many patients included poor service quality (long wait for routine radiograph),
nonpreventable adverse events (previously unknown drug allergy), and deficient
interpersonal skills (physician being rude to patient) as examples of errors.
While wishing that health care were perfect, patients understood that medical
errors were inevitable. The possibility that a medical error might happen
in their care was frightening to patients.
Physicians shared patients' fear of medical errors. One physician described
a sense of dread when he realized that he might have made a medical error:
If something goes wrong with a patient . . . the things that
come to the doctor's mind are "Was it something I prescribed? Was it an instruction
I failed to give? Did I do something wrong?" You get that sinking feeling
probably on a daily basis almost.
Most physicians concurred that they worry regularly about medical errors.
In addition to fearing that an error might harm patients, physicians said
their worst fears about errors included lawsuits, loss of patient trust, the
patient informing friends about their bad experience, loss of colleagues'
respect, and diminished self-confidence. Physicians were frustrated by the
breadth of what patients considered to be errors and thought patients were
often unduly upset about "minor" errors.
Whether to Disclose Errors That Caused Harm
Patients were unanimous in their desire to be told about any error that
caused them harm. Patients believed such disclosure would enhance their trust
in their physicians' honesty and would reassure them that they were receiving
complete information about their overall care. However, patients believed
that "human nature" might lead health care workers to hide errors from patients.
One patient said:
And that's the first instinct . . . something's gone wrong. You
know, hopefully the first thing is to correct it or save the person or whatever,
but the second is cover your hide.
Physicians agreed in principle that patients should be told about any
error that caused harm, and many said such disclosure was ethically imperative.
Some physicians said they would also tell patients about certain errors that
did not cause harm, such as an error that required follow-up testing. However,
physicians agreed with patients that human nature might cause some physicians
to withhold information about errors from patients.
Although physicians endorsed error disclosure in principle, many described
specific situations in which they might not disclose an error that harmed
a patient. Some physicians said there was no need to disclose an error if
the harm was trivial or if the patient was unaware that the error had taken
place. Other physicians believed that certain patients would not want to know
about an error and that informing these patients of an error would diminish
patients' trust in their physician.
You don't want to be accused of scaring people. I've had patients
tell people that I was scaring them when I thought I was simply being informative
and, you know, not being dramatic or anything. But clearly in those cases,
I was telling people more than they wanted to know.
Whether to Disclose Near Misses
Patients had mixed opinions about whether they should be told about
near misses. Some patients thought that hearing about a near miss would alert
them to what errors they should watch for and would reassure them that the
systems to prevent errors from reaching patients were working. Other patients
thought that hearing about a near miss would be upsetting:
I would be more fearful of what might go wrong in the future.
So I would rather not be told.
Most physicians opposed disclosing near misses, feeling such disclosure
would be impractical and could diminish patient trust.
I think if we were held to disclose all of those [near misses],
I think that happens so often we wouldn't have the opportunity to practice
My job is to relieve anxiety, not to create it. And to a certain extent
when an error occurs that doesn't get to the patient, it's not their problem,
it's my problem.
However, a few physicians actually appreciated the opportunity to discuss
near misses with patients.
You form a therapeutic alliance by being in constant communication
with the patient. So to me, a medical error with no adverse event is an opportunity
to form a tighter bond with the patient. You tell them right up front what
happened, what went wrong, you're very sorry it happened. . . . If no adverse
event whatsoever occurs with a medical error, I'm just delighted to tell the
patient exactly what happened.
What Information to Disclose About Harmful Errors
Patients overwhelmingly agreed on what they wanted to be told about
errors that caused harm. Patients wanted to know what happened, the implications
of the error for their health, why it happened, how the problem will be corrected,
and how future errors will be prevented. One patient described how he would
like a physician to tell him about the insulin overdose, emphasizing the importance
of full disclosure and an apology:
I'm sorry, but due to an error of writing instructions and communication
there was a misunderstanding and it caused an overdose of insulin. You have
my deepest sympathy as far as physical problems that we caused for you. However,
we're doing everything within our powers to correct this error, and we can
assure you that this problem will not happen again because I'm not only going
to address it as far as writing the information down, but I'm also going to
communicate it so the nurse will understand what is supposed to be given.
. . . I'm available to sit down and discuss with you in detail what happened,
and again, I'm sorry.
Patients preferred this basic information be provided to them rather
than having to ask their physician numerous questions. While patients wanted
to know about the error expeditiously, they accepted that information about
the error's cause and prevention might take time to collect. Patients wanted
assurances that they would not suffer financially due to the error. Patients
also wanted to know that the practitioner and institution regret what happened,
that they have learned from the error, and that they have plans for preventing
similar errors in the future.
You know, you may have dodged a bullet; you may not. Who knows?
But, hopefully, they will learn from that mistake and that mistake won't be
Some physicians agreed with patients' ideas of how errors should be
disclosed and said they would tell the patient everything they knew about
the insulin error immediately. One physician said he would disclose the cause
of insulin overdose to the patient as follows:
Now, we do have several errors that have happened here. My handwriting
wasn't clear. The nurse should have realized that a hundred units was too
much. The pharmacist should have realized that a hundred units was too much.
. . . That's what happened.
However, in contrast with patients' preferences for full error disclosure,
many physicians were more circumspect regarding exactly what they would tell
patients about errors. These physicians were committed to being truthful but
wanted to put the most positive "spin" on the event as possible.
I think you have to be a spin doctor all the time and put the
right spin on it. . . . I don't think you have to soft pedal the issue, but
I think you try to put it in the best light.
I think you have to be forthright with the patient to help them.
And how you word it makes a big difference.
Many physicians said that fear of litigation limited what they tell
patients about errors.
Everything you read and everything that you're told says that
you are supposed to tell what errors you make as soon as you can. Let them
know what your thinking is, what you are going to do about it. And your chances
of having an adverse litigation are less if you take that approach. Now, the
question is, how many of us believe that?
Many physicians spoke of "choosing their words carefully" when talking
with patients about errors. Most often, this careful choice of words involved
mentioning the adverse event but not explicitly stating that an error took
place. These physicians believed that the patients would ask follow-up questions
about the error if they were interested in more information.
I would be very straightforward and say "You were given too much
insulin. Your blood sugar was lowered and that's how you arrived in the intensive
care unit. You were given some dextrose . . . " and apologize for the events.
And then if they want to know . . . "How did I get too much, or why couldn't
they read your writing, or why didn't they call you?" you go into those individually,
but I wouldn't walk in saying I have sloppy handwriting and they didn't know
what they were reading.
You just tell the facts: "You got a big bunch of insulin and your blood
sugar went down, and we got that fixed up and we're glad you're great."
Physicians chose their words even more carefully when responding to
the hyperkalemia vignette, and few said they would mention the overlooked
laboratory test result. Compared with the insulin example, in which physicians
thought the patient would suspect a medication error, physicians believed
that the hyperkalemia patient would be completely unaware of the error.
I would say something like "I thought this medication was appropriate
for you. I didn't anticipate it to have this response." And I don't disclose
the fact that I didn't check the lab that I was supposed to check.
My approach to this would be to say "I ordered the medicine for you,
one of the effects of which is your potassium went up. I ordered the laboratory
tests. I didn't recognize that it was getting high until the second test.
And it's high, you are having arrhythmias, and we are treating you." I don't
know that I would say "I ordered the test. I tried to find the result. I didn't
get the result. I forgot about it, and I never checked it." I wouldn't say
In both vignettes, physicians were also unlikely to tell the patient
what caused the error and how it might be prevented. None of the physicians
said they would tell the patient anything they personally planned to do to
prevent similar errors in the future, such as avoiding the abbreviation "U"
Patients' Emotions Following an Error
Patients described having a variety of emotional responses after a medical
error. Hearing that an error occurred would make patients feel sad, anxious,
depressed, or traumatized. Patients feared additional errors, were angry that
their recovery had been prolonged, and were frustrated that the error was
preventable. Patients were especially disturbed about errors they thought
were caused by practitioners being careless.
Patients believed that the way the error was disclosed to them directly
affected their emotional experience after the error. Many patients said they
would be less upset if the physician disclosed the error honestly and compassionately
and apologized. Patients thought that explanations of the error that were
incomplete or evasive would increase their distress. Some patients also recommended
having a patient advocate or psychologist assist patients in coping with errors.
Physicians recognized patients' distress following errors and tried
different approaches to addressing these upset feelings. Many physicians said
they would emphasize how glad they were that the error had not been worse
or that the patient was recovering nicely. While some physicians thought it
was helpful to say that they too were upset about the error, other physicians
found this approach "unprofessional" and preferred to focus on the facts of
what happened. Most physicians wanted to apologize but worried that an expression
of regret might be construed by the patient as an admission of legal liability.
You would love to be just straightforward. "Gosh, I wish I had
checked that potassium yesterday. I was busy, I made a mistake, I should have
checked that. I can't believe I wouldn't do that. I will learn from my mistake
and I will do better next time, because this is how we learn as people." But
if you say that to a patient, which you would like to be able to say, honestly,
as just another human being, is that we have this whole thing, the wait to
cash in [through a lawsuit].
Physicians' Emotions Following an Error
Physicians also experienced powerful emotions following a medical error.
Physicians felt upset and guilty about harming the patient, disappointed about
failing to practice medicine to their own high standards, fearful about a
possible lawsuit, and anxious about the error's repercussions regarding their
This is one of the few businesses that is around where you have
to hit a home run every time . . . and I find that the older I get, the longer
I have been at this, the more I worry to the point that this is probably what
is going to drive me out of it, is worrying about it.
For some physicians, the emotional upheaval following an error led to
sleeplessness, difficulty concentrating, and anxiety. Patients said they had
no idea that medical errors caused such problems among physicians. Some patients
welcomed the physician sharing his or her emotions about an error, while other
patients preferred the physician to emphasize that things were under control
following the error.
I was really surprised to hear the doctors talk like that. I
saw a lot more caring than I expected. Caring means communications, their
feelings. You know, most of the time when you see the doctor you don't get
their feelings—yeah, I was surprised.
I am hoping that they are coming in with some real confidence, saying,
"Yeah, I know this was a mistake. I am concerned, but here is how we are going
to handle it." I am sure that physicians deal with that [physicians' upset
feelings], but I don't want to see that side of it. I want to know how can
you help me?
Physicians struggled to find support following a medical error. Some
physicians found talking about an error at a morbidity and mortality conference
to be helpful.
You are supposed to give full disclosure [in the conference].
Don't hold anything back. And it is almost a religious experience. You get
up, you confess your sins. They assign a punishment to you. You sit back down
and you are forgiven for your sins.
Many physicians sought solace by discussing an error with significant
others or a trusted colleague. No physicians reported seeing a counselor or
psychologist about an error. Some physicians said they felt better after disclosing
the error but worried that this relief came at a price to the patient.
[We are] trying to relieve the soul of some burden when we confess
our sins or our errors . . . and dumping that onto the patient is not necessarily
For many physicians, the most difficult challenge was forgiving themselves
for the error.
It helps if the patient says, "Look, I understand that this is
not normal, but I am willing to go along with whatever you say . . . and to
give you that extra support and second chance." Forgiveness is something that
I think is tougher for the physicians to give themselves than to get from
Medical errors are an unfortunate but inescapable part of medical practice.
Our study, the first to our knowledge to jointly investigate patients' and
physicians' attitudes about error disclosure, suggests that the current response
to medical errors may meet neither patients' desire for information about
errors nor the needs of patients and physicians for emotional support following
While patients and physicians largely agreed on whether to tell patients
about errors that cause harm, they disagreed about what to disclose regarding
such errors. Patients unanimously wanted information regarding an error's
cause, consequences, and future prevention. Yet many physicians, while striving
to be truthful, were reluctant to provide patients with this basic information.
For some physicians, error disclosure involved being a "spin doctor," describing
the event in the most positive yet factually accurate light possible. As early
as the 1930s, physicians were advised to "keep a cautious tongue" regarding
medical errors.57 Other studies have also documented
physicians' reluctance to fully disclose errors to patients.15,24,58 Physicians'
wariness in telling patients about errors is often appropriate, reflecting
both fear of litigation and uncertainty about what happened. Other rationale
these physicians offered for not fully informing patients about errors may
be more self-serving, such as the possibility that information about an error
might harm the patient. Few patients shared this concern. Failing to provide
patients with desired information about errors could impair patients' clinical
decision making, diminish patient-physician trust, and increase the likelihood
of a lawsuit.13,59-62
Physicians' reluctance to discuss the cause and future prevention of
errors was especially troubling to patients. Many current institutional policies
about disclosing medical errors instruct physicians not to discuss why an
error happened in a way that could imply fault and to maintain the confidentiality
of error analyses.37 Yet these patients sought
an explanation of why the error occurred—not to affix blame but, rather,
to understand what happened to them and to know that the institution and individuals
involved had learned from the event. Similarly, many patients report filing
malpractice suits so that comparable errors are not repeated.14,42,60,63 Understanding
patients' motivation for wanting full error disclosure may increase physicians'
and institutions' willingness to provide this information. In addition, talking
with patients about error prevention may make disclosure conversations more
positive and less threatening to physicians. The need to tell patients about
an error's cause and prevention could also create stronger links between physicians
and safety programs, reducing future errors.
No consensus emerged regarding whether to tell patients about near misses
(errors that could have caused harm but did not, by either chance or timely
intervention56), an issue on which current
guidelines are largely silent. Knowing about near misses could help patients
make more informed health care choices, reassure patients that mechanisms
to prevent errors from reaching them are working, and dispel their fears that
medical errors might be hidden from them. Talking with patients about near
misses could also help engage patients in error prevention efforts. However,
many patients did not want to know about near misses, and physicians thought
disclosing near misses was impractical. A reasonable approach might be to
tell patients about near misses only if the patient observed the near miss
or has expressed a desire for such information.
Patients' needs for emotional support following an error may also be
going unmet. Physicians' tendency to limit what they tell patients about errors
may actually exacerbate patients' upset emotions. What physicians see as maintaining
an appropriate professional demeanor while discussing an error can strike
the patient as cold and impersonal, creating the mistaken impression that
the physician does not care about what happened or is hiding what actually
happened. Patients in this study wanted physicians to apologize. Physicians
also wanted to apologize but were reluctant to do so for fear of litigation.
Apologizing might, in fact, be a useful approach to resolving both physician
and patient distress after an error. Additional research should seek to resolve
Physicians and institutions can take a number of steps to better meet
patients' needs following an error. Physicians should recognize that they
may not be providing the information patients want about errors and should
disclose the following minimal information about harmful errors regardless
of whether the patient asks: (1) an explicit statement that an error occurred;
(2) a basic description of what the error was, why the error happened, and
how recurrences will be prevented; and (3) an apology. Physicians should encourage
and respond forthrightly to patient's questions and strive to support patients'
emotions. Institutions should ensure their disclosure policies account for
patients' preferences to be fully informed about errors and encourage physicians
to disclose such information to patients.
Health care workers' emotional needs following medical errors may also
be going unmet.26-31 The
notion of a "blame-free" culture of errors did not diminish these physicians'
anguish and sense of culpability for errors. Some physicians turned to the
affected patient for support following errors and, through disclosure, sought
forgiveness from the patient. Most physicians simply struggled to forgive
themselves for what happened. Institutions should assess and support the emotional
needs of practitioners as an explicit component of every error analysis.34,47,64-66 In
addition, continued education of practitioners about the role of faulty systems
in most errors may diminish their distress following errors.1,2,67 Better
institutional support for caregivers involved in errors would help them focus
their attention on the affected patient.7,32,34,35,44
Our study has a number of limitations. We studied a self-selected sample
of patients and physicians in 1 geographic area, which may limit the generalizability
of our results. In addition, our qualitative methods do not allow us to determine
the exact proportion of patients or physicians who held any given attitude.
However, the themes we have reported are those that recurred independently
in each focus group, enhancing our confidence that these themes accurately
reflect the general attitudes of patients and physicians.
Patients' needs for information and emotional support following harmful
medical errors may be going unmet. In particular, we found that patients and
physicians have notably different perspectives on what information should
be disclosed about medical errors. Designing patient-centered strategies for
responding to medical errors will require a better understanding of patients'
needs following a medical error and the barriers that prevent physicians from
meeting these needs. In addition, health care institutions should strengthen
their support of the emotions of practitioners who are involved in medical
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