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BUILDING THE FOUNDATIONS OF A MEDICATION SAFETY PROGRAMME IN AN ACUTE HOSPITAL (submitted in 2019)

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European Statement

Patient Safety and Quality Assurance

Author(s)

Bernie Love, Tracy McFadden, Patrick Martin, Val Connolly, Deirdre Brennan, Michelle Griffin, Danielle Bracken, Siobhan Maguire, James Carr

Why was it done?

Avoidable harm caused by medication is one of the most commonly reported adverse events in healthcare settings.

What was done?

Connolly Hospital Blanchardstown launched a formal Medication Safety Programme in November 2017 by appointing a Medication Safety Facilitator and establishing a multidisciplinary Medication Safety Committee to promote and support the safe use of medications. The Medication Safety Committee undertook a number of activities to establish the programme in the hospital.

How was it done?

-An evidence-based literature review to define and guide the scope, breadth and direction of the programme. -A baseline in-depth analysis of locally reported medication incidents (2016/2017) on the National Incident Management System (NIMS) was conducted to identify initial targets for improvement. Analysis was undertaken using NCC-MERP, a recognised and validated tool used specifically for medication incidents. -An annual work-plan, incorporating necessary elements of a medication safety programme, was devised by the committee defining goals for the year.

What has been achieved?

Safety Culture:  Prominent commitment from hospital management to medication safety.  Investigations into medication errors aligned to a just and fair systems approach.  Promotion and encouragement of medication safety reporting and learning with a Medication Safety Awareness Day.  Implementation of the ‘Know, Check, Ask’ campaign to enhance medication safety by empowering patients. Governance:  Organogram updated to reflect reporting relationship of new committee.  Medication Safety made standing item at Quality & Safety Executive meetings.  Annual report submitted to Hospital Executive Committee Measurement & Monitoring of medication incidents:  Quarterly report produced and disseminated to front-line staff tracking and trending medication incidents including narratives.  Performance indicators established for: -No. of incidents reported (2018 reporting increased by 32% over 2017); -Reporter of incidents; -Category of harm; -Stage of medication use process where incidents have occurred. Education & Training:  Regular face-to-face education sessions arranged with front-line staff.  Quarterly medication safety bulletin devised and disseminated, informed by audit findings and incident reports.  The successful Medication Safety Minute initiative from St James’s Hospital was adopted and implemented, with content informed by local incidents. Development, Updating and Dissemination of PPPGs.  New IV drug administration guides (n=53) developed and updated.  Introduction of one-page ‘Medicines Information Sheet’ as quick reference guides for key topics.  DOAC prescription and administration guide developed and circulated. Audit:  Audit programme established informed by incident analysis, complaints and best-practice including introduction of an ‘audit window’ to gather hospital-wide data. Quality Improvement:  Informed by incident analysis, best-practice and audit findings, a number of moderate-high leverage quality improvement projects were initiated including removal of concentrated potassium from general clinical areas, introduction of an insulin & glucose monitoring record and introduction of an automated dispensing cabinet for out-of-hours access to medication.

What next?

The structural aspects established for the Medication Safety Programme have been successful in establishing a programme in the hospital and are reproducible by other centres.
Work continues in Connolly Hospital to identify themes of incidents, audit of practice and implementation of quality improvement initiatives.

AN AUDIT OF DISCHARGE PRESCRIPTIONS FOR SURGICAL AND MEDICAL PATIENTS WITH A QUALITY IMPROVEMENT INITIATIVE (submitted in 2019)

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European Statement

Patient Safety and Quality Assurance

Author(s)

Eva Heffernan, Deirdre Smith , Avril Tierney, Louise McDonnell

Why was it done?

Transitions of care such as hospital discharge present an opportunity for medication error. Lapses in communication at this interface are common. For the next healthcare provider (HCP) to issue the correct medication safely and in a timely manner, the discharge prescription needs to bridge this communication gap. Prescribing errors are the most frequent subtype of medication errors and can be repeated systematically for prolonged periods. Detection of medication error using tools such as audit, learning from these errors and planning corrective action is essential to building safer healthcare systems.
This study adapted the Health Information and Quality Authority (HIQA) national standard for patient discharge summaries to create a benchmark for discharge prescriptions in SVPH. A QI initiative targeting prescribers was developed. This was designed as a bundle intervention and was called the Discharge Prescription Education Bundle (DPEB).

What was done?

The aim of this project was to evaluate the current level of discrepancies on discharge prescriptions for surgical and medical patients and to ascertain if a quality improvement (QI) initiative can impact on the severity of medication error at the point of discharge.

How was it done?

Uncontrolled consecutive baseline and re-audit of discharge prescriptions on a 26-bed mixed medical and surgical ward. The baseline audit assessed 70 patients’ discharge prescriptions. Deviations from the standard were termed discrepancies. Discrepancies were divided based on capacity to cause error (NCC-MERP Category A) and error occurred (NCC-MERP Category B-I). Discrepancies where an error occurred (NCC-MERP Category B-I) were reported using the in-house medication incident reporting (MIR) system and dually assessed by an independent panel and the project lead for potential to cause harm. The QI initiative was implemented and its impact assessed with a re-audit of 70 patients’ discharge prescriptions.

What has been achieved?

The overall number of discrepancies reduced from 156 in the baseline to 59 in the re-audit (p<0.05). Overall compliance with the audit standards improved from 17.1% to 54.3% (p <0.05). In the baseline audit 22.8% (n=16) of patients had a discrepancy where an error occurred; this reduced to 2.65% (n=2) in the re-audit (p<0.05). The severity of errors reduced in the re-audit.

What next?

The QI initiative used was proactive not reactive. Use of the discharge education bundle was not restricted to pharmacy opening hours.
This initiative was very low cost to implement. Following on from the successful results of this project one component of DPEB called the discharge prescription visual prompt is now preprinted on all SVPH discharge prescriptions as a reminder to prescribers.

A NOVEL CLOSED SYSTEM DRUG-TRANSFER DEVICE FOR ORAL DOSAGE FORM HELPING PATIENTS WHO CANNOT SWALLOW SOLIDS (submitted in 2019)

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European Statement

Patient Safety and Quality Assurance

Author(s)

SALIM HADAD

Why was it done?

It remains that new solutions to increasing the safety of handling Solid Dosage Form hazardous drugs have to be developed. Conceptually, through operating in a closed system, CSTDs should significantly reduce the risks to pharmacists and nurses There are two main drawbacks of the known solutions:
1. The crushing and dilution of the solid dosage form medicine is done with an open vessel to the environment, such as a porcelain crater, which may cause the work environment to be contaminated with carcinogenic or teratogenic substances, that could expose and endanger the medical staff to hazardous substances in the course of their duties as providers of medical care.
2. The tools available today are reusable, requiring a thorough cleaning process between different materials (drugs), which can lead to cross-contamination between different doses of drugs, which are crushed one after the other with the same instrument.

What was done?

CSTD – for oral dosage form new device of its kind, combines the act of crushing the various drugs, dissolve in liquid and give to a patient who cannot swallow for various reasons, that mechanically prohibits the transfer of environmental contaminants into the system and the escape of hazardous drug or vapor concentrations outside the system.

How was it done?

We designed the device with 3D software (solid wark). It consists of a number of functional parts. The main ones are: a 20 ml barrel, a top part of which is a piston with a bottom basket loaded with the solid medicine; this part is sealed as a barrel from above. With the help of mechanical rotation, the drug breaks down into small particles that fall into the inner space of the barrel. Adding the liquid through a fluid port disposed on the bottom barrel which it is completely sealed. The removal of the liquid drug through a unique adapter which at its end is adapted to the gastric tube or oral administration to the patient,

What has been achieved?

1. The complete process of crushing and liquefying of the solid drugs is carried out under sealed conditions to the immediate environment and without fear of exposure to residues of toxic substances to the medical caregiver. 2. A one-time use system saves complex cleaning process. 3. There is no risk of cross-contamination between different drugs. 4. Saving personal protective equipment such as gloves, masks, lab coats clean rooms, etc. which is necessary for protection and for the safety of the caregiver team.

What next?

Applied research will be carried out by pharmacists and nurses to test the efficiency of the new device (as a basic prototype). These experiments will take various non-cytotoxic pills, will be dummy operations, in which the crushing and liquefying will be performed, and the solution or suspension will be transferred through the gastric tube, according to an approved research protocol.

STANDARDISATION OF DILUTED POTASSIUM INTRAVENOUS SOLUTIONS IN NEONATAL CARE UNITS (submitted in 2019)

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European Statement

Patient Safety and Quality Assurance

Author(s)

Luis Pérez de Amezaga Tomás, María Magdalena Parera Pascual, Mónica Sanz Muñoz, Catalina March Frontera, Gonzalo González Morcillo, Alejandra Mandilego Garcia, Álvaro Medina Guerrero, Ana Filgueira Posse, Montserrat Vilanova Boltó

Why was it done?

Administration of intravenous KCl produces hyperkalaemia and this can result in cardiac arrest and death. The Institute for Safe Medication Practices (ISMP) as well as other security agencies have recommended the withdrawal of KCl 2M from ward stock. This project was born as a response to these recommendations. We focused on a group of patients where these practices have not been extensively implemented. The aim of the protocol was to standardise the prescription, preparation, dispensation and administration of KCl to neonates in our hospital.

What was done?

Development of a protocol that standardises diluted potassium intravenous solutions for neonates (including those preterm over 28 weeks of gestation). This allowed us to remove concentrated potassium chloride (KCl) 2M from neonatal care units in our hospital. For this purpose, the hospital pharmacy centralised the preparation and distribution of KCl ready-to-use infusions.

How was it done?

The elaboration of the protocol took place as follows: • A multidisciplinary team designed KCl ready-to-use solutions that met the requirements of the newborn: – Glucose 10% 250mL with 5 mEq KCl (20mEq/L solution) – Glucose 10% 250mL with 10 mEq KCl (40mEq/L solution). • The hospital pharmacy centralised the preparation of these solutions. A risk assessment was performed and determined an expiration date of 7 days. • These solutions were stocked at all neonatal care units: Intensive Care Unit, Hospitalized Paediatric Unit and Paediatric Emergency Unit. • Weekly, the hospital pharmacy distributes these solutions and disposes of the expired ones. • Only ready-to-use KCl solutions were able to prescribe at the electronic prescription programme. • A formation plan was implemented to train all the professionals involved in neonatal care.

What has been achieved?

The protocol was implemented in November 2016. Since then, 65 patients have been treated with 20mEq/L solution and only 1 patient with 40mEq/L solution. No remarkable imbalances in electrolytes have been detected resulting from the standardisation of the fluid therapy with KCl. Only 3 incidents have been registered. All of them were prescription errors (solution selection); they reached the patient but without damage.

What next?

Nowadays, we are developing a stability study of the KCl solutions in order to assess the appropriateness of the expiration date.

IMPACT OF A MEDICATION REQUEST TOOL FROM THE NURSING ADMINISTRATION VIEW IN HOSPITALISATION (submitted in 2019)

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European Statement

Patient Safety and Quality Assurance

Author(s)

M. T. Barrera, O. Carrascosa, P. Madrid, A. Aguado, R. Martínez , N. Argüello, E. Cuellar, M. Vela, C. Jimenez, S. Payan, O. Sánchez

Why was it done?

Lack of stock delays medication administration by nurses. This situation also generates hospital warden displacements to Pharmacy Service and telephone interruptions of Pharmacy technicians’ work. The main aim was to amend stock lack management to improve patient security during medication preparation and administration. The secondary objectives were: reduce interruptions of other health professionals and automate warehouse exits, avoiding errors of manual updating of Pharmacy stock.

What was done?

This tool is part of “Safe Medication Administration in Hospitalization/Avoid Interruptions” project. A “button” was included in the nursing administration view of the electronic prescription programme, which when activated automatically generates a request to the Pharmacy Service for a dose of required medication. Hospital Information Systems were contacted for the design. All requests generated during the administration of medication were automatically received in Pharmacy Service. They were grouped by plant, listed, deducted from stock and dispensed at the agreed times.

How was it done?

The tool was developed by Hospital Information Systems, in collaboration with nursing, and staff training was carried out for correct handling of the tool. Also, medication dispensing schedules were agreed with the hospital warden. 15 days before tool implementation, the Pharmacy Service analysed all medication requests made from hospitalisation. Data collected were: plant and shift requested, reason, existence of pattern, requested medication, requested units, notice to auxiliaries to collect medication. After the first week of implementation, the same assessment of requests was made during the same period to compare and evaluate the impact of this tool implementation.

What has been achieved?

When both periods were compared, prescribed medication requests decreased from 198 to 15, this difference being statistically significant (Fisher’s exact test p=0.008). This difference meant significant reduction of interruptions in Pharmacy technicians’ daily work. Requests reasons were lack of dose in 43.4% (n=95) of cases, immediate prescriptions in 29.2% (n=64) of cases and treatment change in 20.5% (n=45) of cases. 29.2% of all requested medications belonged to the antimicrobial and antiviral group. 62% (n=135) of the total requests were received in the morning shift. Hospital warden displacements were significantly reduced when comparing both periods from 102 to 3 (Chi square test, p=0.006). This meant a significant reduction in interruptions in hospital warden work. It has been possible to standardise and improve efficiently nursing management of medication stock lack.

What next?

The incidents technical improvement is pending, as well as training of new nursing staff. It is possible to implement this tool in all hospital units that have electronic prescription.

ENHANCING MEDICATION SAFETY BY IMPLEMENTING AND IMPROVING THE USE OF A SMART PUMP DRUG LIBRARY IN A TERTIARY HOSPITAL (submitted in 2019)

European Statement

Patient Safety and Quality Assurance

Author(s)

Mohammed Almeziny, Maha Aljuhanei , Fahad Alkharji

Why was it done?

Smart infusion pumps have been introduced to prevent medication errors and they have been widely adopted by healthcare. They incorporate safeguards such as soft and hard dosage limits.

What was done?

A smart pump was implemented in a tertiary hospital.

How was it done?

A task group was formulated from all involved parties to cover all issues related to practice, and it involved nursing and pharmacy staff to overcome all obstacles that may face the project; in addition the information technology (IT) department was involved to determine the facilitation of all technical issues. At the beginning the group faced two main barriers: creating the initial drug library which was a significant amount of work for the pharmacy, then uploading the drug library. In addition, all these works were to be carried out manually by the medical engineering. The quantitative data available from the smart pump software were used to improve drug library use. The team started to collect feedback from and communicate feedback to direct care nurses about drug library usage via e-mail, staff meetings, a “whatsapp” group and one-on-one conversations. This included asking nurses why the drug library was not being used regularly. The most frequent responses included “The pump is hard to use,” “The list doesn’t have the medications I need and, “It’s just easier to use the rate-based programming feature”.

What has been achieved?

The pump library usage percentage for total infusions was raised from a baseline of 2.85% to 30.97% in the first week. After careful review by the nursing, pharmacy, and medical leadership, some changes to the library were made. These included standardising drug concentrations in the pump library and providing ongoing staff education as well as implementing the best practices cited in the ISMP’s guidelines for the use of smart pumps; and running daily usage and weekly soft limit override reports from the pump library. Furthermore, a new category, “feeding”, was added to pump library; finally all medications and plain fluids were added to the pump library.

What next?

A Bar-Code Medication Administration System is needed (BCMA), to ensure the right patient gets the correct drug, dose and route at the right time.

IMPLEMENTATION OF A MEDICATION RECONCILIATION PROGRAMME UPON DISCHARGE (submitted in 2019)

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European Statement

Patient Safety and Quality Assurance

Author(s)

José Marco-del Río, María Luisa Ibarra-Mira, Gregorio Romero-Candel, Ana Ramirez-Córcoles, Ana Valladolid-Walsh, Francisco Tomás Pagán-Nuñez

Why was it done?

Our main goal was to improve patient’s safety, because we noticed that many patients did not take actually all the drugs that were prescribed by the physicians, and other times there were drugs that the patients were taking because they had an active prescription, but they were not supposed to. Additionally, we aimed to improve the drug-related information that the patients take home.

What was done?

A programme which includes every patient admitted into the Internal Medicine department. It consists of three steps: clarification of chronic medication that the patients are taking, we handle them and updated schedule of their drugs upon discharge and we check the coherence with the active prescriptions.

How was it done?

We interview the patients during the admission in order to clarify and update the chronic medication that they are taking. When a patient is about to be discharged, the nurses call us, so at this moment we talk to the physician to know what changes are going to be made on the medication. To coordinate with the physicians and nurses, we had two meetings in which we established the timing of the programme, so the patients don’t have to wait too long for us. When we know the changes that the physician is going to make, we update the medication schedule to handle it to the patients or their family, and we explain to them the changes and how they should manage the new drugs. If any discrepancy or medication-related problem is detected, we talk to the physician to solve it.

What has been achieved?

In the last four months, we performed 180 discharges and we solved together with the physicians 20 discrepancies. Patients are now receiving more comprehensive information about their treatment.

What next?

To continue with the programme and broaden it to the rest of our hospital departments. Also we are working on a way of uploading our pharmacy schedules to the electronic medical record of the patients, so they can be available for every healthcare worker, which would improve even more the transitions of care.

PROCEDURE TO ENSURE CORRECT MEDICATION MANAGEMENT IN THE PERIOPERATIVE PROCESS (submitted in 2019)

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European Statement

Patient Safety and Quality Assurance

Author(s)

Noelia Vicente Oliveros, María Muñoz García, Álvaro Ruigomez Saiz, Montserrat Ferre Masferrer, Teresa Bermejo Vicedo, Eva Delgado Silveira, Lucía Quesada Muñoz, Ana María Alvarez-Diaz

Why was it done?

An analysis of the indicators of the perioperative process reflected the need to improve their quality. One of the causes of scheduled surgery cancellation was the lack of the follow up of the anaesthetist’s medication recommendations. Medications need to be carefully managed to prevent perioperative complications.

What was done?

We designed and implemented a flow chart to ensure the patient compliance of anesthetist’s medication recommendations prior to surgery. We designed a protocol for the perioperative medication management.

How was it done?

A multidisciplinary group was formed with the management of the hospital and representatives of all the services involved in the perioperative process. The group designed the flow chart of the process by consensus. Patients were candidates to enter in this process if they were on treatment with anticoagulant or 2 or more medications from the following groups: antiplatelet, antihypertensives, antidiabetics. A pharmacist called by phone three times (the day before, the day of medication change, and the day after) to the patient to ensure the compliance of anaesthetist recommendations. If there was a lack of compliance, the pharmacist contacted the surgeon who was in charge of deciding if the surgery procedure continued as scheduled. Moreover, the domiciliary medication of these patients were reconcilliated and recorded in their health record. Healthcare professionals could consult it during hospital stay. The group designed a protocol for the perioperative medication management with different medical specialists.

What has been achieved?

The project started in April 2019. The pharmacist called patients with scheduled surgery of lower limbs. A total of 31 patients benefited from the new flow chart. The pharmacist detected 38 medication errors; two involved errors concerning the suspension of anticoagulant drugs prior to surgery and four implied antihypertensive drugs. Once, it was necessary to contact the surgeon. In this case, the surgeon decided to continue with the surgery as schedule. Fifty-seven medications suffered a change in the period between the anaesthestic visit and the surgery, nine of them belonged to the monitored medication group. 

What next?

The next steps are to spread the flow chart to other patients, to distribute the protocol among hospital healthcare professionals and to implement a procedure for the reintroduction of the modified medication.

SAFETY IMPROVEMENT IN PAEDIATRICS: ASSISTED PRESCRIPTION OF INTRAVENOUS MIXTURES (submitted in 2019)

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European Statement

Patient Safety and Quality Assurance

Author(s)

Iván Maray Mateos, Miguel Alaguero Calero, Adrián Rodriguez Ferreras, Cristina Calzón Blanco, Cristina Álvarez Asteinza, Lucía Velasco Roces, Ana Lozano Blazquez

Why was it done?

Intravenous drugs in the paediatric population bring up additional issues than the usual in adults. In their prescription, not only does the dose have to be adapted to the patient’s weight, the volume in which the drug is diluted must also be adapted to the reduced fluids requirement without jeopardising the stability of the mixture. In view of these facts, IV drug prescription in paediatrics implies a higher risk of medication errors. This new prescribing system simplifies prescription and reduces risks.

What was done?

Development of an assisted prescription system of intravenous mixtures adapted to paediatric patients in which both the drug dose and the diluent volume are automatically calculated according to the patient’s weight.

How was it done?

A literature review of drug dosing in paediatrics and their stability in different diluents was performed. For every drug the following parameters were considered: maximum dose in children (mg/kg), maximum concentration allowed (mg/ml), common doses and volumes in adults. Using these values, a system was built which calculated drug dose and diluent volume according to the patient’s weight and the maximum concentration allowed for stability reasons. For safety and to ease the preparation, the diluent volume in millilitres was rounded up to the next 10. In order to avoid overdosing overweight or older paediatric patients, maximum dose and diluent volume were narrowed down to the usual quantities in adults. Ultimately, this system was integrated in the electronic prescription system. A protocol was created, named “drug name” IV mixture PEDIATRICS. So, by selecting this protocol in a specific patient, the target dose and the diluent volume are automatically calculated.

What has been achieved?

This system was implemented for 38 drugs. From July 2018 to April 2019, 910 IV mixtures have been prescribed from the following Anatomical Therapeutic Chemical (ATC) groups: A02 Drugs for acid related disorders (39), J01 Antibacterials for systemic use (287), J02 Antimycotics for systemic use (3), J05 Antivirals for systemic use (8), A04 Antiemetics and antinauseants (175), N02 Analgesics (395), N03 Antiepileptics (3).

What next?

This method could be implemented in other electronic prescription programmes. The system must be updated by the Pharmacy Department, introducing new drugs and constantly reviewing stability databases, posology regimens, and information regarding dilution of parenteral drugs.

THE OPIOID WORKING GROUP: AN INTERDISCIPLINARY WORKING GROUP TO IMPROVE THE CORRECT PRESCRIPTION AND APPLICATION OF OPIOIDS IN THE HOSPITAL SETTING (submitted in 2019)

European Statement

Patient Safety and Quality Assurance

Author(s)

Imke Willrodt, Delia Bornand, Jimena Ramos, Stojan Petkovic, Giulia Mohr, Anne Leuppi-Taegtmeyer

Why was it done?

Due to critical incidents involving opioids reported internally at the University Hospital Basel in 2018, there was an urgent need to evaluate underlying reasons for these events. The Opioid AG was established with the aim to mitigate risks for the correct prescription and application of opioids, and therefore to improve patient safety.

What was done?

The Opioid Working Group at the University Hospital Basel is an interdisciplinary working group including representatives from different professions (physicians, nurses, pharmacists) and departments (medical, surgery, gynaecology, emergency, pain therapy, palliative care, pharmacology and toxicology, patient safety and information technology).

How was it done?

The thorough analysis of root causes for the critical incidents revealed prescribing and application errors, such as non-observance of kidney failure, pharmacodynamic interactions of opioids with other prescribed drugs, inadvertent overdosing – in particular with liquid drug formulations, or patient mix-ups.

What has been achieved?

Consequently, the following steps are being taken to address these risks: 1. Optimisation of the prescribing software including opioid prescription templates, links to existing opioid unit conversion tables for liquid forms of diamorphine, morphine, hydrocodone and oxycodone (milligrams to millilitres) as well as clearer display of “as required” opioid prescriptions on the patients’ electronic drug charts. 2. Preparation of Standard Medication Preparation Schemes for nursing staff of the emergency department. 3. Development of an additional label (concentration, patient initials, date of reconstitution, date of expiry of reconstituted solution) for parenteral diamorphine. 4. Improvement in detailed written instructions for the correct preparation, labelling, application and disposal of intravenous and oral drugs (to include opioids). 5. Evaluation of a hospital opioid safety self-assessment tracking tool.

What next?

A comprehensive evaluation will take place, 6 months after the implementation of all measures. We will use the number of naloxone prescriptions on the wards as a key performance indicator to measure the success of this project. The reported critical incidents involving opioids will also be assessed before and after the implementation of all measures.

This evaluation will help to identify open questions, potential gaps and further needs for improvement to be addressed by the interdisciplinary team.

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