MEDITECH MAGIC BLOOD BANK SOFTWARE
Report
- Report Number
- 1222805-2009-00001
- Event Type
- Malfunction
- Date Received
- November 5, 2009
- Date of Event
- October 9, 2009
- Report Date
- November 4, 2009
- Manufacturer
- MEDICAL INFORMATION TECHNOLOGY, INC.
- Product Code
- MMH
- PMA / PMN Number
- BK060029
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- TN, US
- Reporter Occupation
- OTHER HEALTH CARE PROFESSIONAL
Narratives
DEVICE AVAILABLE FOR EVAL: THE BLOOD BANK SOFTWARE AND DATABASE AT THE CUSTOMER LOCATION IS AVAILABLE TO MEDITECH STAFF THROUGH A DIAL-UP CONNECTION. THE CUSTOMER SITE HAS TWO SEPARATE DATABASES WITH THE SAME VERSION OF SOFTWARE: A TEST DATABASE USED FOR RESEARCH, TESTING, AND VERIFICATION; AND A LIVE DATABASE USED FOR RECORDING THE DAILY OPERATIONS OF THE HOSPITAL'S BLOOD BANK. EVAL OF THE MALFUNCTION: INVESTIGATION OF THE SOFTWARE IN THE HOSPITAL'S TEST DATABASE AND IN MEDITECH'S CONTROLLED TESTING ENVIRONMENT FOUND THAT THE MALFUNCTION RESULTED IN A DATA INTEGRITY ERROR. THE BLOOD BANK HISTORIES OF A LIMITED NUMBER OF DONORS, UNITS, AND PTS' WERE COMPROMISED. DONATED UNITS AND THE ASSOCIATED UNIT SPECIMENS APPEARED ON THE INCORRECT DONOR HISTORY RECORD. THE HISTORY RECORD WAS SHOWING UNKNOWN BLOOD TYPE, NOT THE WRONG BLOOD TYPE. FIVE DONOR HISTORY RECORDS WERE AFFECTED, HOWEVER, NO ACTIONS WERE TAKEN WHICH RESULTED IN HARM TO ANY PATIENTS OR DONORS. THE SOFTWARE HAS THE FOLLOWING MITIGATIONS WHICH WOULD PREVENT OR REDUCE THE LIKELIHOOD OF PT INJURY: THE AFFECTED BLOOD BANK HISTORIES ARE 'FROZEN'. THE SYSTEM WOULD PREVENT ANY ACTION ON A PT OR DONOR WITH A 'FROZEN' HISTORY. THE SYSTEM WOULD REQUIRE A USER WITH AUTHORITY AND SPECIFIED ACCESS TO REVIEW THE 'FROZEN' HISTORY BEFORE RELEASING IT. REVIEW OF THE 'FROZEN' HISTORY WOULD REVEAL THAT THE BLOOD BANK HISTORY HAS CONFLICTING DATA. TRACEABILITY OF DONATED UNITS IS MAINTAINED THROUGH UNIT INQUIRY AND DONOR INQUIRY. THE SYSTEM WOULD REQUIRE A NEW SPECIMEN AND BLOOD TYPE RESULTS IN ORDER TO UNDERTAKE A CROSSMATCH. THE SYSTEM WOULD REQUIRE A FULL CROSSMATCH TO CHECK THE COMPATIBILITY OF A UNIT BEFORE TRANSFUSION. ADDITIONAL MODEL NUMBER: 5.6.
ON (B)(6) 2009, A FACILITY REPORTED THAT DATA ON DONORS INAPPROPRIATELY COMBINED WHEN A USER EDITED THE NAME OF A DONOR. RESEARCH CONDUCTED ON (B)(6) 2009 REVEALED THAT EDITING THE ENTRY AT THE "MEDICAL RECORD" FIELD IN THE DONOR ROUTINE COULD MALFUNCTION AND CAUSE INCORRECT RECORD ASSN. IF THE "MEDICAL RECORD" WAS EDITED IN A MANNER THAT DID NOT SELECT AN EXISTING MEDICAL RECORD, THE DONOR WAS REASSIGNED A NEW INTERNAL MEDICAL RECORD NUMBER. IF ANOTHER DONOR WAS THEN SIMILARLY EDITED, THAT DONOR WOULD BE ASSIGNED TO THE SAME INTERNAL MEDICAL RECORD, WHICH WOULD CAUSE THE SECOND DONOR'S HISTORY TO BE COMBINED INTO THE FIRST DONOR'S HISTORY. ON (B)(6) 2009, MEDITECH CORRECTED MAGIC RELEASE VERSIONS 5.5 AND 5.6 SUCH THAT IF THE MEDICAL RECORD FIELD IS EDITED, THE SYSTEM WILL EITHER REQUIRE A VALID MEDICAL RECORD OR NOT ASSIGN A MEDICAL RECORD. ON (B)(6) 2009, MEDITECH DISTRIBUTED A NOTIFICATION TO CUSTOMERS. CODE CHANGES ARE BEING PROVIDED TO ALL CUSTOMERS WHO COULD BE IMPACTED. MEDITECH HAS RETESTED THE DEVICE AFTER THE CORRECTION AND DETERMINED THAT THE SOFTWARE IS WORKING AS INTENDED. MEDITECH HAS PROVIDED CUSTOMERS WITH TOOLS TO EVALUATE THE INTEGRITY OF DATA AND SUPPORT TO CORRECT ANY DATA ERRORS. (B)(6).
DEVICE AVAILABLE FOR EVAL: THE BLOOD BANK SOFTWARE AND DATABASE AT THE CUSTOMER LOCATION IS AVAILABLE TO MEDITECH STAFF THROUGH A DIAL-UP CONNECTION. THE CUSTOMER SITE HAS TWO SEPARATE DATABASES WITH THE SAME VERSION OF SOFTWARE: A TEST DATABASE USED FOR RESEARCH, TESTING, AND VERIFICATION; AND A LIVE DATABASE USED FOR RECORDING THE DAILY OPERATIONS OF THE HOSPITAL'S BLOOD BANK. EVAL OF THE MALFUNCTION: INVESTIGATION OF THE SOFTWARE IN THE HOSPITAL'S TEST DATABASE AND IN MEDITECH'S CONTROLLED TESTING ENVIRONMENT FOUND THAT THE MALFUNCTION RESULTED IN A DATA INTEGRITY ERROR. THE BLOOD BANK HISTORIES OF A LIMITED NUMBER OF DONORS, UNITS, AND PTS' WERE COMPROMISED. DONATED UNITS AND THE ASSOCIATED UNIT SPECIMENS APPEARED ON THE INCORRECT DONOR HISTORY RECORD. THE HISTORY RECORD WAS SHOWING UNKNOWN BLOOD TYPE, NOT THE WRONG BLOOD TYPE. FIVE DONOR HISTORY RECORDS WERE AFFECTED, HOWEVER, NO ACTIONS WERE TAKEN WHICH RESULTED IN HARM TO ANY PATIENTS OR DONORS. THE SOFTWARE HAS THE FOLLOWING MITIGATIONS WHICH WOULD PREVENT OR REDUCE THE LIKELIHOOD OF PT INJURY: THE AFFECTED BLOOD BANK HISTORIES ARE 'FROZEN'. THE SYSTEM WOULD PREVENT ANY ACTION ON A PT OR DONOR WITH A 'FROZEN' HISTORY. THE SYSTEM WOULD REQUIRE A USER WITH AUTHORITY AND SPECIFIED ACCESS TO REVIEW THE 'FROZEN' HISTORY BEFORE RELEASING IT. REVIEW OF THE 'FROZEN' HISTORY WOULD REVEAL THAT THE BLOOD BANK HISTORY HAS CONFLICTING DATA. TRACEABILITY OF DONATED UNITS IS MAINTAINED THROUGH UNIT INQUIRY AND DONOR INQUIRY. THE SYSTEM WOULD REQUIRE A NEW SPECIMEN AND BLOOD TYPE RESULTS IN ORDER TO UNDERTAKE A CROSSMATCH. THE SYSTEM WOULD REQUIRE A FULL CROSSMATCH TO CHECK THE COMPATIBILITY OF A UNIT BEFORE TRANSFUSION. ADDITIONAL MODEL NUMBER: 5.6.
ON (B)(6) 2009, A FACILITY REPORTED THAT DATA ON DONORS INAPPROPRIATELY COMBINED WHEN A USER EDITED THE NAME OF A DONOR. RESEARCH CONDUCTED ON (B)(6) 2009 REVEALED THAT EDITING THE ENTRY AT THE "MEDICAL RECORD" FIELD IN THE DONOR ROUTINE COULD MALFUNCTION AND CAUSE INCORRECT RECORD ASSN. IF THE "MEDICAL RECORD" WAS EDITED IN A MANNER THAT DID NOT SELECT AN EXISTING MEDICAL RECORD, THE DONOR WAS REASSIGNED A NEW INTERNAL MEDICAL RECORD NUMBER. IF ANOTHER DONOR WAS THEN SIMILARLY EDITED, THAT DONOR WOULD BE ASSIGNED TO THE SAME INTERNAL MEDICAL RECORD, WHICH WOULD CAUSE THE SECOND DONOR'S HISTORY TO BE COMBINED INTO THE FIRST DONOR'S HISTORY. ON (B)(6) 2009, MEDITECH CORRECTED MAGIC RELEASE VERSIONS 5.5 AND 5.6 SUCH THAT IF THE MEDICAL RECORD FIELD IS EDITED, THE SYSTEM WILL EITHER REQUIRE A VALID MEDICAL RECORD OR NOT ASSIGN A MEDICAL RECORD. ON (B)(6) 2009, MEDITECH DISTRIBUTED A NOTIFICATION TO CUSTOMERS. CODE CHANGES ARE BEING PROVIDED TO ALL CUSTOMERS WHO COULD BE IMPACTED. MEDITECH HAS RETESTED THE DEVICE AFTER THE CORRECTION AND DETERMINED THAT THE SOFTWARE IS WORKING AS INTENDED. MEDITECH HAS PROVIDED CUSTOMERS WITH TOOLS TO EVALUATE THE INTEGRITY OF DATA AND SUPPORT TO CORRECT ANY DATA ERRORS. (B)(6).
DEVICE AVAILABLE FOR EVAL: THE BLOOD BANK SOFTWARE AND DATABASE AT THE CUSTOMER LOCATION IS AVAILABLE TO MEDITECH STAFF THROUGH A DIAL-UP CONNECTION. THE CUSTOMER SITE HAS TWO SEPARATE DATABASES WITH THE SAME VERSION OF SOFTWARE: A TEST DATABASE USED FOR RESEARCH, TESTING, AND VERIFICATION; AND A LIVE DATABASE USED FOR RECORDING THE DAILY OPERATIONS OF THE HOSPITAL'S BLOOD BANK. EVAL OF THE MALFUNCTION: INVESTIGATION OF THE SOFTWARE IN THE HOSPITAL'S TEST DATABASE AND IN MEDITECH'S CONTROLLED TESTING ENVIRONMENT FOUND THAT THE MALFUNCTION RESULTED IN A DATA INTEGRITY ERROR. THE BLOOD BANK HISTORIES OF A LIMITED NUMBER OF DONORS, UNITS, AND PTS' WERE COMPROMISED. DONATED UNITS AND THE ASSOCIATED UNIT SPECIMENS APPEARED ON THE INCORRECT DONOR HISTORY RECORD. THE HISTORY RECORD WAS SHOWING UNKNOWN BLOOD TYPE, NOT THE WRONG BLOOD TYPE. FIVE DONOR HISTORY RECORDS WERE AFFECTED, HOWEVER, NO ACTIONS WERE TAKEN WHICH RESULTED IN HARM TO ANY PATIENTS OR DONORS. THE SOFTWARE HAS THE FOLLOWING MITIGATIONS WHICH WOULD PREVENT OR REDUCE THE LIKELIHOOD OF PT INJURY: THE AFFECTED BLOOD BANK HISTORIES ARE 'FROZEN'. THE SYSTEM WOULD PREVENT ANY ACTION ON A PT OR DONOR WITH A 'FROZEN' HISTORY. THE SYSTEM WOULD REQUIRE A USER WITH AUTHORITY AND SPECIFIED ACCESS TO REVIEW THE 'FROZEN' HISTORY BEFORE RELEASING IT. REVIEW OF THE 'FROZEN' HISTORY WOULD REVEAL THAT THE BLOOD BANK HISTORY HAS CONFLICTING DATA. TRACEABILITY OF DONATED UNITS IS MAINTAINED THROUGH UNIT INQUIRY AND DONOR INQUIRY. THE SYSTEM WOULD REQUIRE A NEW SPECIMEN AND BLOOD TYPE RESULTS IN ORDER TO UNDERTAKE A CROSSMATCH. THE SYSTEM WOULD REQUIRE A FULL CROSSMATCH TO CHECK THE COMPATIBILITY OF A UNIT BEFORE TRANSFUSION. ADDITIONAL MODEL NUMBER: 5.6.
ON (B)(6) 2009, A FACILITY REPORTED THAT DATA ON DONORS INAPPROPRIATELY COMBINED WHEN A USER EDITED THE NAME OF A DONOR. RESEARCH CONDUCTED ON (B)(6) 2009 REVEALED THAT EDITING THE ENTRY AT THE "MEDICAL RECORD" FIELD IN THE DONOR ROUTINE COULD MALFUNCTION AND CAUSE INCORRECT RECORD ASSN. IF THE "MEDICAL RECORD" WAS EDITED IN A MANNER THAT DID NOT SELECT AN EXISTING MEDICAL RECORD, THE DONOR WAS REASSIGNED A NEW INTERNAL MEDICAL RECORD NUMBER. IF ANOTHER DONOR WAS THEN SIMILARLY EDITED, THAT DONOR WOULD BE ASSIGNED TO THE SAME INTERNAL MEDICAL RECORD, WHICH WOULD CAUSE THE SECOND DONOR'S HISTORY TO BE COMBINED INTO THE FIRST DONOR'S HISTORY. ON (B)(6) 2009, MEDITECH CORRECTED MAGIC RELEASE VERSIONS 5.5 AND 5.6 SUCH THAT IF THE MEDICAL RECORD FIELD IS EDITED, THE SYSTEM WILL EITHER REQUIRE A VALID MEDICAL RECORD OR NOT ASSIGN A MEDICAL RECORD. ON (B)(6) 2009, MEDITECH DISTRIBUTED A NOTIFICATION TO CUSTOMERS. CODE CHANGES ARE BEING PROVIDED TO ALL CUSTOMERS WHO COULD BE IMPACTED. MEDITECH HAS RETESTED THE DEVICE AFTER THE CORRECTION AND DETERMINED THAT THE SOFTWARE IS WORKING AS INTENDED. MEDITECH HAS PROVIDED CUSTOMERS WITH TOOLS TO EVALUATE THE INTEGRITY OF DATA AND SUPPORT TO CORRECT ANY DATA ERRORS. (B)(6).
DEVICE AVAILABLE FOR EVAL: THE BLOOD BANK SOFTWARE AND DATABASE AT THE CUSTOMER LOCATION IS AVAILABLE TO MEDITECH STAFF THROUGH A DIAL-UP CONNECTION. THE CUSTOMER SITE HAS TWO SEPARATE DATABASES WITH THE SAME VERSION OF SOFTWARE: A TEST DATABASE USED FOR RESEARCH, TESTING, AND VERIFICATION; AND A LIVE DATABASE USED FOR RECORDING THE DAILY OPERATIONS OF THE HOSPITAL'S BLOOD BANK. EVAL OF THE MALFUNCTION: INVESTIGATION OF THE SOFTWARE IN THE HOSPITAL'S TEST DATABASE AND IN MEDITECH'S CONTROLLED TESTING ENVIRONMENT FOUND THAT THE MALFUNCTION RESULTED IN A DATA INTEGRITY ERROR. THE BLOOD BANK HISTORIES OF A LIMITED NUMBER OF DONORS, UNITS, AND PTS' WERE COMPROMISED. DONATED UNITS AND THE ASSOCIATED UNIT SPECIMENS APPEARED ON THE INCORRECT DONOR HISTORY RECORD. THE HISTORY RECORD WAS SHOWING UNKNOWN BLOOD TYPE, NOT THE WRONG BLOOD TYPE. FIVE DONOR HISTORY RECORDS WERE AFFECTED, HOWEVER, NO ACTIONS WERE TAKEN WHICH RESULTED IN HARM TO ANY PATIENTS OR DONORS. THE SOFTWARE HAS THE FOLLOWING MITIGATIONS WHICH WOULD PREVENT OR REDUCE THE LIKELIHOOD OF PT INJURY: THE AFFECTED BLOOD BANK HISTORIES ARE 'FROZEN'. THE SYSTEM WOULD PREVENT ANY ACTION ON A PT OR DONOR WITH A 'FROZEN' HISTORY. THE SYSTEM WOULD REQUIRE A USER WITH AUTHORITY AND SPECIFIED ACCESS TO REVIEW THE 'FROZEN' HISTORY BEFORE RELEASING IT. REVIEW OF THE 'FROZEN' HISTORY WOULD REVEAL THAT THE BLOOD BANK HISTORY HAS CONFLICTING DATA. TRACEABILITY OF DONATED UNITS IS MAINTAINED THROUGH UNIT INQUIRY AND DONOR INQUIRY. THE SYSTEM WOULD REQUIRE A NEW SPECIMEN AND BLOOD TYPE RESULTS IN ORDER TO UNDERTAKE A CROSSMATCH. THE SYSTEM WOULD REQUIRE A FULL CROSSMATCH TO CHECK THE COMPATIBILITY OF A UNIT BEFORE TRANSFUSION. ADDITIONAL MODEL NUMBER: 5.6.
ON (B)(6) 2009, A FACILITY REPORTED THAT DATA ON DONORS INAPPROPRIATELY COMBINED WHEN A USER EDITED THE NAME OF A DONOR. RESEARCH CONDUCTED ON (B)(6) 2009 REVEALED THAT EDITING THE ENTRY AT THE "MEDICAL RECORD" FIELD IN THE DONOR ROUTINE COULD MALFUNCTION AND CAUSE INCORRECT RECORD ASSN. IF THE "MEDICAL RECORD" WAS EDITED IN A MANNER THAT DID NOT SELECT AN EXISTING MEDICAL RECORD, THE DONOR WAS REASSIGNED A NEW INTERNAL MEDICAL RECORD NUMBER. IF ANOTHER DONOR WAS THEN SIMILARLY EDITED, THAT DONOR WOULD BE ASSIGNED TO THE SAME INTERNAL MEDICAL RECORD, WHICH WOULD CAUSE THE SECOND DONOR'S HISTORY TO BE COMBINED INTO THE FIRST DONOR'S HISTORY. ON (B)(6) 2009, MEDITECH CORRECTED MAGIC RELEASE VERSIONS 5.5 AND 5.6 SUCH THAT IF THE MEDICAL RECORD FIELD IS EDITED, THE SYSTEM WILL EITHER REQUIRE A VALID MEDICAL RECORD OR NOT ASSIGN A MEDICAL RECORD. ON (B)(6) 2009, MEDITECH DISTRIBUTED A NOTIFICATION TO CUSTOMERS. CODE CHANGES ARE BEING PROVIDED TO ALL CUSTOMERS WHO COULD BE IMPACTED. MEDITECH HAS RETESTED THE DEVICE AFTER THE CORRECTION AND DETERMINED THAT THE SOFTWARE IS WORKING AS INTENDED. MEDITECH HAS PROVIDED CUSTOMERS WITH TOOLS TO EVALUATE THE INTEGRITY OF DATA AND SUPPORT TO CORRECT ANY DATA ERRORS. (B)(6).
DEVICE AVAILABLE FOR EVAL: THE BLOOD BANK SOFTWARE AND DATABASE AT THE CUSTOMER LOCATION IS AVAILABLE TO MEDITECH STAFF THROUGH A DIAL-UP CONNECTION. THE CUSTOMER SITE HAS TWO SEPARATE DATABASES WITH THE SAME VERSION OF SOFTWARE: A TEST DATABASE USED FOR RESEARCH, TESTING, AND VERIFICATION; AND A LIVE DATABASE USED FOR RECORDING THE DAILY OPERATIONS OF THE HOSPITAL'S BLOOD BANK. EVAL OF THE MALFUNCTION: INVESTIGATION OF THE SOFTWARE IN THE HOSPITAL'S TEST DATABASE AND IN MEDITECH'S CONTROLLED TESTING ENVIRONMENT FOUND THAT THE MALFUNCTION RESULTED IN A DATA INTEGRITY ERROR. THE BLOOD BANK HISTORIES OF A LIMITED NUMBER OF DONORS, UNITS, AND PTS' WERE COMPROMISED. DONATED UNITS AND THE ASSOCIATED UNIT SPECIMENS APPEARED ON THE INCORRECT DONOR HISTORY RECORD. THE HISTORY RECORD WAS SHOWING UNKNOWN BLOOD TYPE, NOT THE WRONG BLOOD TYPE. FIVE DONOR HISTORY RECORDS WERE AFFECTED, HOWEVER, NO ACTIONS WERE TAKEN WHICH RESULTED IN HARM TO ANY PATIENTS OR DONORS. THE SOFTWARE HAS THE FOLLOWING MITIGATIONS WHICH WOULD PREVENT OR REDUCE THE LIKELIHOOD OF PT INJURY: THE AFFECTED BLOOD BANK HISTORIES ARE 'FROZEN'. THE SYSTEM WOULD PREVENT ANY ACTION ON A PT OR DONOR WITH A 'FROZEN' HISTORY. THE SYSTEM WOULD REQUIRE A USER WITH AUTHORITY AND SPECIFIED ACCESS TO REVIEW THE 'FROZEN' HISTORY BEFORE RELEASING IT. REVIEW OF THE 'FROZEN' HISTORY WOULD REVEAL THAT THE BLOOD BANK HISTORY HAS CONFLICTING DATA. TRACEABILITY OF DONATED UNITS IS MAINTAINED THROUGH UNIT INQUIRY AND DONOR INQUIRY. THE SYSTEM WOULD REQUIRE A NEW SPECIMEN AND BLOOD TYPE RESULTS IN ORDER TO UNDERTAKE A CROSSMATCH. THE SYSTEM WOULD REQUIRE A FULL CROSSMATCH TO CHECK THE COMPATIBILITY OF A UNIT BEFORE TRANSFUSION. ADDITIONAL MODEL NUMBER: 5.6.
ON (B)(6) 2009, A FACILITY REPORTED THAT DATA ON DONORS INAPPROPRIATELY COMBINED WHEN A USER EDITED THE NAME OF A DONOR. RESEARCH CONDUCTED ON (B)(6) 2009 REVEALED THAT EDITING THE ENTRY AT THE "MEDICAL RECORD" FIELD IN THE DONOR ROUTINE COULD MALFUNCTION AND CAUSE INCORRECT RECORD ASSN. IF THE "MEDICAL RECORD" WAS EDITED IN A MANNER THAT DID NOT SELECT AN EXISTING MEDICAL RECORD, THE DONOR WAS REASSIGNED A NEW INTERNAL MEDICAL RECORD NUMBER. IF ANOTHER DONOR WAS THEN SIMILARLY EDITED, THAT DONOR WOULD BE ASSIGNED TO THE SAME INTERNAL MEDICAL RECORD, WHICH WOULD CAUSE THE SECOND DONOR'S HISTORY TO BE COMBINED INTO THE FIRST DONOR'S HISTORY. ON (B)(6) 2009, MEDITECH CORRECTED MAGIC RELEASE VERSIONS 5.5 AND 5.6 SUCH THAT IF THE MEDICAL RECORD FIELD IS EDITED, THE SYSTEM WILL EITHER REQUIRE A VALID MEDICAL RECORD OR NOT ASSIGN A MEDICAL RECORD. ON (B)(6) 2009, MEDITECH DISTRIBUTED A NOTIFICATION TO CUSTOMERS. CODE CHANGES ARE BEING PROVIDED TO ALL CUSTOMERS WHO COULD BE IMPACTED. MEDITECH HAS RETESTED THE DEVICE AFTER THE CORRECTION AND DETERMINED THAT THE SOFTWARE IS WORKING AS INTENDED. MEDITECH HAS PROVIDED CUSTOMERS WITH TOOLS TO EVALUATE THE INTEGRITY OF DATA AND SUPPORT TO CORRECT ANY DATA ERRORS. (B)(6).
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 1 | MEDITECH MAGIC BLOOD BANK SOFTWARE | MAGIC BLOOD BANK | MMH | MEDICAL INFORMATION TECHNOLOGY, INC. | 5.5 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | ||||
| 2 | ||||
| 3 | ||||
| 4 | ||||
| 5 |