Patient Safety Culture In Hospitals Research Articles

Nursing communication handover in emergency department

Introduction Effective communication in the transition of care is fundamental to improve patient safety and contribute to the reduction of adverse events [1]. A study carried out in 2014, in fifty-five hospital units in Portugal, under the “Evaluation of Patient Safety Culture in Hospitals”, concluded that patient safety culture is not yet widely acknowledged as a priority for health professionals [2], and that 70% of adverse health events occur due to communication failures among health professionals during the transition of care. Ineffective communication can be found in different health contexts, being more frequent during the transition of care, when it is essential to manage situations quickly and effectively. The peri-operative period, the ICU and emergency department are examples of contexts where communication processes are complex and prone to errors. Objective To know nurses opinion about the transition of care in the emergency department, as well as their knowledge on the patient safety. Materials and Methods This is a descriptive and exploratory study with a quantitative approach. Non-probabilistic and convenience sample. This study intends to answer the following research questions: What is the opinion of the emergency department nurses about the time of transition of care during shift change? Do nurses know the guidelines for patient safety in the care transition? A questionnaire was used as a data collection instrument. It consists of three parts: a first part on sample characterisation; a second part that seeks to know the opinion of nurses about the transition of care in the change of shift; and a third part, with the objective of assessing nurses' knowledge on patient's safety. The questionnaire was applied during the month of January 2019. Results Of the total of seventy questionnaires delivered fifty were returned, with a response rate of 67.57%. The sample is essentially composed of women (82%), with a mean age of 33.46 years. They have on average 10.67 years as nurses and 7.29 years as nurses in the emergency department. With regard to nurses' opinion on the transition of care during shift change, four domains were found, namely: Positive aspects of the nursing care transition moment; Negative aspects of the nursing care transition moment; Patient evaluation at the moment of nursing care transition; and management of the information obtained during the nursing care transition. Regarding nurses' knowledge on patient safety, three areas were identified: Knowledge of the guidelines on effective communication in the transition of care; Benefits of using a standard tool in the transition of care, and training in the area of patient safety. Discussion and conclusions: Nurses feel that there are a number of factors that interfere with the transition of care; there is irrelevant information that is transmitted in the moment of transition of care and the ISBAR methodology contributes to decision-making and critical thinking. It is important to promote team training in the area of patient safety. Nurses have the legal obligation to ensure continuity of care through effective communication, using existing resources, namely the ISBAR tool.

Assessing Patient Safety Culture in Hospital Settings.

The current knowledge about patient safety culture (PSC) in the healthcare industry, as well as the research tools that have been used to evaluate PSC in hospitals, is limited. Such a limitation may hamper current efforts to improve patient safety worldwide. This study provides a systematic review of published research on the perception of PSC in hospitals. The research methods used to survey and evaluate PSC in healthcare settings are also explored. A list of academic databases was searched from 2006 to 2020 to form a comprehensive view of PSC’s current applications. The following research instruments have been applied in the past to assess PSC: the Hospital Survey on Patient Safety Culture (HSPSC), the Safety Attitudes Questionnaire (SAQ), the Patient Safety Climate in Health Care Organizations (PSCHO), the Modified Stanford Instrument (MSI-2006), and the Scottish Hospital Safety Questionnaire (SHSQ). Some of the most critical factors that impact the PSC are teamwork and organizational and behavioral learning. Reporting errors and safety awareness, gender and demographics, work experience, and staffing levels have also been identified as essential factors. Therefore, these factors will need to be considered in future work to improve PSC. Finally, the results reveal strong evidence of growing interest among individuals in the healthcare industry to assess hospitals’ general patient safety culture.

The Impact of a National Accreditation Program on Patient Safety Culture in a Tertiary Hospital: Pre- and Post-Evaluation Study.

The objective of this study was to assess the effectiveness of the Saudi national accreditation program on patient safety culture in a secondary-tertiary public hospital in Saudi Arabia. Three hundred health professionals were randomly selected to participate in a survey. The survey was used in three phases: baseline, before accreditation, and after accreditation. Primary and secondary outcome measures were teamwork within hospital units, feedback and communication about errors, hospital handoffs and transitions, overall perceptions of safety, frequency of event reporting, and perception of patient safety grade. The survey response rate was 100%. A statistically significant impact of accreditation was found for teamwork within hospital units, feedback and communication about errors, and hospital handoffs and transitions (p = 0.002, 0.009, and 0.010, respectively). Ordinal logistic regression confirmed that the accreditation program had a significant effect on overall perceptions of safety (odds ratio [OR] [1.42-13.56], p = 0.010), frequency of event reporting (OR [0.91-7.96], p = 0.073), and staff awareness of grading safety culture (OR [0.02-0.70]) and reporting behavior (OR 0.10 [0.03-0.37]). The Saudi national accreditation program had a significant positive impact on some patient safety culture dimensions and outcomes. These findings provide local empirical evidence on the benefits of implementing national accreditation programs. Further research on a larger scale is highly recommended.

The Relationship Between Charge Nurses and Clinical Nurses' Perceptions of Patient Safety Culture and Leadership Practices

Background: A patient safety culture needs to be developed for quality and safe care in health care institutions. Executive nurses having transformational leadership behavior have an important effect on establishing a patient safety culture in hospitals. Objectives: The aim of this study is to reveal transformational leadership practices of unit charge nurses from their own perspective and the perspective of staff nurses they work with, to determine the patient safety culture perceptions of unit charge nurses and staff nurses, and to examine the relationship between transformational leadership practices and patient safety culture. Methods: This descriptive, relationship-seeking and cross-sectional study was conducted between March and June 2014 in four hospitals in Konya province. The sample of the study consisted of 70 unit charge nurses and 357 staff nurses working with these unit charge nurses. Participation rate in the study is 84.5%. Data were collected by using the Demographic Data Form, Leadership Practices Inventory and Patient Safety Culture Hospital Questionnaire. Means, t test, percentages, standard deviation and Spearman's tests were used in the analysis of the data. Results: According to the evaluations of the unit charge nurses and staff nurses; it was found that the unit charge nurses' averages scores for prodding others into action, encouraging others and questioning the process sub-dimension and total leadership practice were significantly higher than those of the staff nurses. Patient Safety Culture perceptions of unit charge nurses are higher than service nurses. According to the findings obtained from the study, there is a positive relationship between nurses' transformational leadership practices and patient safety culture. Conclusion: In the study, it has been shown that there is a positive relationship between nurses' transformational leadership practices and patient safety culture. In order to create a positive patient safety culture in the units of charge nurses, it is necessary to develop the unit charge nurses' transformational leadership practices.

Assessment of patient safety culture in Brazilian hospitals through HSOPSC: a scoping review

to describe, from literature, the characteristics of patient safety culture in Brazilian hospitals that applied the Hospital Survey on Patient Safety Culture. this is a scoping review. A search was performed in the databases LILACS, PubMed, SciELO, CINAHL, Web of Science, Scopus and in the CAPES Dissertations and Theses Database in September and October 2020. thirty-six studies were identified. Nine studies identified strengthened areas such as: "teamwork within the units", "expectations of supervisor/boss and actions promoting safety", "organizational learning", "support of hospital management for patient safety" and "frequency of report of events". As a critical area, the dimension "non-punitive response to error" was evidenced in 30 of 36 studies. the identification of areas of strength and critical areas of safety culture is relevant to encourage improvement of patient safety problems in an institution.

Questionnaire for assessing patient safety culture in emergency services: an integrative review.

to identify the instruments used to assess patient safety culture in emergency settings. an integrative literature review conducted from 2000 to 2018. 13 instruments were identified to assess patient safety culture in hospital and pre-hospital emergencies, comprising 12 to 50 questions, grouped from three to 12 dimensions, with dimensions related to teamwork, support, and management actions for patient safety and for continuous process improvement and continuing education. The Emergency Medical Service Safety Attitude Questionnaire, which is exclusive for pre-hospital care, stands out. the choice and the best decision regarding the instrument are linked to the objectives, the environment and the population to be investigated, as well as the instrument's reliability.

Assessment of Patient Safety Culture in Public General Hospital in Capital City of Vietnam.

Patient safety culture is a vital component in ensuring high quality and safe patient care. Assessment of staff perception on existing hospital patient safety culture (PSC) is the first step to promote PSC. This paper is aimed to assess the patient safety culture in 1 big public autonomous general hospital in Hanoi, Vietnam. This cross-sectional study surveyed 638 healthcare professional utilizing the validated (Hospital Survey on Patient Safety Culture [HSOPSC]) in an online format. This study adhered to STROBE guidelines. The positive response rate was high, with a percentage of 74.2. The strongest areas are teamwork within units (91.3%) and organizational learning/continuous improvement (88.4%). The areas for improvement are staffing (49.4%) and non-punitive response to error (53.1%). Hospital administrators should strengthen the culture of patient safety by formulating strategies and implementing interventions with emphasis on adequate staffing and promoting blame-free working environment.

PATIENT SAFETY CULTURE IN PERSPECTIVE OF MILLENNIALS: CASE STUDY IN A MALAYSIAN PRIVATE HOSPITAL

This case study investigated the nature of patient safety culture in a Malaysian private hospital. This was accomplished by studying the general perception of patient safety with a survey questionnaire and insights from open comments. The Donabedian framework of quality was used to further analyse the nature of patient safety culture from the perspective of millennials. Findings from the interviews were triangulated with data from observations and document reviews, which were interpreted based on the High Reliability Organisation (HRO) principles. They revealed that the structures and concerns in the practice environment regard the artificial intelligence (AI) system, human capital management, and manpower, while processes such as communication, teamwork and collaboration issues, and training and improvements are vital. Patient safety culture outcomes which depend on structures and processes indicated the need for improvements in the frequency of events reported. The main implication of this study is that to raise standards of care to those in an HRO and in a complex care environment, a paradigm shift from current reactive standards towards a more proactive safety system, based on flexibility and stability, would be necessary. This requires a strong case organisation to note appropriate structures and processes affecting eventual outcomes.

Assessing the Medical Staff’s Overall Satisfaction of Patient Safety Culture from a Regional Teaching Hospital in Taiwan

Abstract This study adds an additional question to the existing Chinese version of the safety attitudes questionnaire (SAQ) to discuss the relationships between the dimensions of the Chinese version of SAQ and the overall perception of the patient safety culture in a regional teaching hospital in Taiwan from the viewpoint of the medical staff. This study uses linear regression with forward selection to assess the perceptions from all of the medical staff by using the data sets in 2015 and 2016. The input variables are eight dimensions, whereas the dependent variable is the overall satisfaction of the patient safety culture in this hospital. The results show that four dimensions are found to significantly affect the overall satisfaction of the patient safety culture. Moreover, it is found that working conditions is the most important dimension in these two years and has the most positive impact on the overall satisfaction. Hospital management needs to pay more attention to working conditions first. In addition to working conditions, safety climate is the other essential dimension identified in both 2015 and 2016; that is, hospital management needs to have a strong and proactive organizational commitment to safety for all of the medical staff to improve the overall satisfaction of the patient safety culture.

Cultural Barriers and Enablers for Event Reporting

The purpose of this work was to identify opportunities for increasing event reporting based on a national survey on patient safety culture in a radiation medicine department. The National Hospital Patient Safety Culture Survey developed by the Agency for Healthcare Research and Quality (AHRQ) was disseminated to all staff members of our multi-center radiation medicine department via a web-based tool (Survey Monkey). The overall survey score was the fraction of responses deemed favorable for patient safety as per AHRQ guidelines. Apart from demographic questions, all 42 Likert-scale questions of the survey were mandatory. Completed surveys were amalgamated, and scores computed overall, per question, and per department work staff division. An additional survey question probed respondents on their annual frequency of event reporting with 6 choices ranging from none to over 21. The fraction of responses other than “None” yielded the event reporting rate. Linear regression analysis was performed for the division event reporting rate with each of the 42 questions scored per division. In addition, members of the incident learning system (ILS) analysis team completed an in-house survey to compare the impact of our internal ILS with the national Radiation Oncology Incident-Learning System (RO-ILS) in our department. The overall patient safety culture score was 67.8% (AHRQ average 65%). The department event reporting rate was 49% (> 50th and <75th percentile of all AHRQ respondents). The event reporting rate trends correlated well with survey scores on 4 of the 42 questions (Pearson correlation coefficient > 0.70, p-value <0.05). These were 1) It is just by chance that more serious mistakes don't happen around here (66.4% disagreed); 2) Staff feel like their mistakes are held against them (54% disagreed); 3) My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures (71.9% agreed); and 4) Mistakes have led to positive changes here (66.4% agreed). In the 2nd survey 82% of the respondents felt that having an ILS improves patient safety culture. 100% felt that even low-severity reports should be filed as fixing such errors may help improve processes in the long run. Neither ILS had a distinct relative advantage towards making our culture safer, but there were slight differences between perceptions of use patterns. Enablers for event reporting include staff perceiving a systematic department effort towards safety, a non-punitive environment for reporting, management appreciation for staff complying with safety guidelines, and impactful departmental responses to reported mistakes. Opposing perceptions are barriers. Having an ILS alongside a culture that supports even low-severity event reporting is perceived to improve reporting and patient safety. The AHRQ survey may be potentially useful for other departments seeking similar insights.

The relationship between leadership style and nurse's work motivation with the implementation of patient safety culture in hospital, Bone regency

To identify the dominant leadership style and to analyze the relationship between leadership style and nurse's work motivation with the implementation of the patient safety culture of the inpatient installation in the c class hospital of Bone regency. This is a cross-sectional study which involved 104 nurses in total sampling. Data were analyzed using the chi-square test. The dominant leadership style of the inpatient nurse managers is transactional, with a percentage of 69.2%. There was a significant relationship between leadership style (p<0.05) and nurse's work motivation (p<0.05) with the application of patient safety culture, respectively. The transactional leadership has an impact on independent culture, and the combination of extrinsic and intrinsic motivation has an impact on creating public service motivation, which is good to build reporting and learning the culture.

Cultura de seguridad del paciente en un hospital de alta especialidad

Introducción. La cultura de seguridad del paciente permite trabajar de manera multidisciplinaria, identificar vulnerabilidades y modificar áreas de oportunidad para disminuir riesgos que pudieran propiciar un error que cause daño al paciente. Objetivo. Describir el grado de cultura de seguridad del paciente en un hospital de alta especialidad. Métodos. Estudio cuantitativo, descriptivo y transversal, con técnica de muestreo aleatorio simple. Se aplicó el cuestionario Hospital Survey on Patient Safety Culture, de la Agency for Healthcare Research and Quality. Bajo las pautas SQUIRE para mejorar la atención médica. Resultados. El porcentaje general del grado de cultura de seguridad del paciente fue 45.1%, la percepción del personal sobre el grado de seguridad global del paciente 8.1/ 10. La fortaleza principal: Trabajo en equipo con 75.3%. Variables críticas: Personal, dotación, suficiencia y gestión (28.8%), Problemas en cambios de turno (34.8%) y Respuesta no punitiva a errores (21.5%). Conclusiones. Toda institución debe identificar las fortalezas y áreas de oportunidad, con el objetivo de vigilar los procesos que conllevan a mejorar la seguridad en atención y disminuir los sesgos que propician el error.

Areas of Potential Improvement for Hospitals' Patient-Safety Culture in Western Ethiopia.

BackgroundPatient-safety culture is an important component of health-care quality and currentlyan issue of high concern globally. In Ethiopia, little is known about patient-safety culture in hospitals. We assessed the patient-safety culture and associated factors among health-care workers in public hospitals of East Wollega Zone, western Ethiopia.MethodsThis institution-based cross-sectional study was conducted among 421 health-care workers selected using simple random sampling from March 4 to March 29, 2019. A standardized measuring 12 patient safety–culture components was used for data collection. Data were cleaned and entered into EpiData version 3.1 and analysis done using SPSS version 25 (IBM). Bivariate and multivariate linear regression analyses were performed. Significance was set at 95% CI and p<0.05, and unstandardized β-coefficients were used to measure extent of association.ResultsThis study revealed that the level of patient-safety culture was 49.2% and patient safety culture–component scores ranged from 29.2% for nonpunitive responses to error to 77.9% for teamwork within a hospital unit. Age ≥45 years (β=13.642, CI: 5.324–21.959; p=0.001), 1–5 years’ experience at the current hospital (β=5.559, 95% CI 2.075–9.042; p=0.002), and working in general hospitals (β=11.988, 95% CI 7.233–16.743; p<0.001) and primary hospitals (β=6.408, 95% CI 2.192–10.624; p=0.003) were factors associated with better scores on patient-safety culture.ConclusionOverall scores for patient-safety culture were low. Improving the current state of patient safety in public hospitals would require tailored interventions to address low-scoring components, such as nonpunitive responses to error.

Measuring patient safety culture: A study at a teaching hospital in Ghana

Objective This study examined the current patient safety culture from the perspective of healthcare workers in a teaching hospital in Ghana and drew comparison with the Agency for Healthcare Research and Quality 2018 Patient Safety Culture Comparative Database Report. Methods A cross-sectional survey was conducted using the Hospital Survey on Patient Safety Culture developed by the Agency for Healthcare Research and Quality. A total of 435 questionnaires were distributed and 322 valid responses were received (a response rate of 74%). The study sample included 178 nurses, 59 doctors, 19 pharmacists, 35 technicians ((laboratory and radiology), and 31 management staff. The Hospital Survey Excel Tool 1.6 and the Statistical Package for the Social Sciences (SPSS) version 20 were used to analyze the data. Results The overall average score for the 12 dimensions of patient safety culture was 53% which is 12% lower than the Agency for Healthcare Research and Quality 2018 benchmark report of 65%. The dimension with the highest positive mean score was “Teamwork within Hospital Units” (77%) while the one with the lowest score was “Frequency of Event Reporting” (33%). All 12 domains except for Frequency of Event Reporting ( p = 0.414), Management Support for Patient Safety ( p = 0.823), and Teamwork within Units ( p = 0.070) have significant relationship with patient safety culture. Conclusions Generally, the patient safety culture dimension in the teaching hospital was low. Training of healthcare workers on patient safety and a broad based research including all categories of healthcare staff is highly needed in other to fully understand and change the patient safety culture in Ghanaian Hospitals.

Current Status and Predictors of Patient Safety Culture in Hospitals of Qassim Region, Saudi Arabia

Background and ObjectivesThe emerging concept of safety culture has been increasingly recognized as an issue of global importance. Measuring the Patient Safety Culture (PSC) of healthcare facilities helps in highlighting areas requiring improvement as well as tracking changes over time. Our study aimed to describe the current status and predictors of PSC in hospitals of Qassim Region, Saudi Arabia.MethodsIn 2016–2017, data on PSC were collected from 1460 staff members in five hospitals using the Hospital Survey on Patient Safety Culture instrument. The data were analyzed using descriptive statistics, Chi-square test (χ2), analysis of variance, and linear regression analysis.ResultsTeamwork within units received the highest score (mean score = 3.95/5), whereas nonpunitive response to errors received the lowest score (mean score = 2.25/5). The study has identified four PSC dimensions requiring improvement: teamwork across units, staffing, handoffs and transitions, and nonpunitive response to errors. In general, the categories of new hires and pharmacists were more likely to negatively perceive PSC dimensions. Furthermore, approximately half of the variance in PSC perception scores was explained by teamwork within units, organizational learning, hospital management support, teamwork across units, and nonpunitive response to errors.ConclusionPatient safety culture of any healthcare setting is not a simple paradigm, applying system changes to the healthcare systems remains vital to improve safety. It is essential to build an environment that support staff to speak up freely about their concerns regarding any safety issues.

Factors related to Patient Safety Accident in Long-term Care Hospitals: Focused on Patient, Nurse, and Hospital Factors

Purpose The purpose of this study was to determine the factors related to patient safety accidents in long-term care hospitals. Methods The participants were 50 patients who had safety accidents during a hospitalization period and 100 patients who had no safety accidents, and were hospitalized during the same period, and had the same gender, age, and underlying diseases as the accident group. A complete enumeration survey was conducted on 85 nurses working in three long-term care hospitals. Results The patient safety accident rate was 0.62 persons per 1000 hospital days. Regarding harmful incidents of patient safety accidents, step 1 harmful incidents accounted for the highest rate (56.0%). Regarding the type of accident, falls accounted for the highest rate (46.0%). Regarding the place of accidents, hospital rooms accounted for the highest rate (72.0%). The accident group and the non-accident group had statistically significant differences in cardiac disorders, sedative hypnotics, vasodilators, nootropic agents, antibiotics, wearing an adult diaper, and physical restraints. In terms of nurses, the accident experience group and the non-experience group had a statistically significant difference in their work career (x2=7.69, p=.027). The patient safety culture score was statistically significantly different between hospital 1 and hospital 2 (F=11.07, p=.003). Conclusion It is necessary to develop systems and strategies that handle all three factors to enhance the patient safety culture in the long-term care hospitals. 주요어: í™˜ìžì•ˆì „, 환자, 간호사, 요양병원 Key Words: Patient safety, Patients, Nurses, Long-term care

A cross-sectional study of patient safety culture in acute-care hospitals in Greece

Background The development of a culture of safety can bring about an improvement in patient safety and quality of care. We aimed to investigate patient safety culture within an acute-care hospital setting in Greece. Methods A cross-sectional quantitative study was conducted using the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire in two large acute-care hospitals in Greece. We examined questionnaire’s factorial structure using confirmatory and exploratory factor analysis. We assessed scales’ internal consistency, test–retest reliability and construct validity. To assess changes in patient safety culture, we conducted surveys at two points in time (2009 and 2014). Regression analysis examined whether any changes in scale scores could have been due to quality programs implementation or participants’ professional characteristics. Results Six scales with satisfactory psychometric properties emerged, namely ‘Teamwork Across Hospital Units’, ‘Teamwork Within Hospital Units’, ‘Feedback and Communication About Error’, ‘Frequency of Event Reporting’, ‘Supervisor/Manager Expectations and ‘Actions Promoting Safety’, ‘Hospital Management Support for Patient Safety’. Overall ratings of patient safety did not change over time. However, one of the two institutions experienced an increase in reported events. Conclusions The HSOPSC is a valuable tool for assessing patient safety culture in Greece. Moreover, despite the radical reduction in the financing of the Greek National Health System reported between 2009 and 2014, patient safety culture did not deteriorate. A worldwide trend towards increasing patient safety awareness, along with the increasing effort of hospitals’ administration to support patient safety might explain this lack of differences between the two points in time.

NURSES’ PERCEPTION ON PATIENT SAFETY CULTURE IN CRITICAL CARE AREA AT A TERTIARY HOSPITAL IN PAHANG, MALAYSIA

Patient safety culture is important in measuring the quality of health care. There is a need for the establishment of patient safety culture in hospitals as it is one of the global issues that requires attention. Issues such as medication errors are the third leading cause of death in the US and approximately one in ten patients have been reported being harmed while receiving hospital treatment. Adverse events such as bed falls, adverse drug effects, infections, work overload and absenteeism have become the matters of risk for the patient’s safety. Nevertheless, research that is related to patient safety were less studied in the healthcare area especially dealing with ill patients in the Intensive Care Unit (ICU).

Pomiar i ocena kultury bezpieczeństwa pacjenta w warszawskich szpitalach za pomocą polskiej adaptacji amerykańskiego kwestionariusza Hospital Survey on Patient Safety Culture

Pomiar i ocena kultury bezpieczeństwa pacjenta w warszawskich szpitalach za pomocą polskiej adaptacji amerykańskiego kwestionariusza Hospital Survey on Patient Safety Culture

Relationship between Patient Safety Culture and Adverse Events in Hospital: A case study

Introduction: Patient safety culture is an important factor in reducing hospital's adverse event and improving patient safety. The aim of this study was to evaluate the relationship between patient safety culture and adverse events in hospitals of Hamadan city. Methods: The present study was a descriptive-analytical study which was performed in hospitals of Hamadan in 2018. The study population consisted of nurses working in hospitals. The patient safety culture questionnaire and adverse event checklist were used for data collection. Questionnaires were completed by 650 nurses. Multiple logistic regression was used to examine the relationship between the variables. Results: The highest mean score of patient safety culture was related to the dimension of organizational learning, and the lowest score was for exchange and transfer of information. 35.4 percent of nurses said they had seen at least one patient fall in the past year (the least adverse event). Moreover, 51.9 percent of nurses stated that at least one pressure ulcer, or a complaint by a patient or his/her family had happened at their workplace in the past year (the most adverse event). Finally, the mean score of the patient safety culture had a significant relationship with the incidence of adverse events. Conclusion: This study confirms the patient safety culture as a predictor of adverse events. Hence, health officials and hospital administrators should provide prerequisites for promoting patient safety culture and reducing adverse events through different strategies, such as encouraging adverse events reporting as well as holding nurse training courses. © 2020. All Rights Reserved.