ࡱ> F1Ҭq'd֚ ؉b糴 +)Vk]|o#ՈppY3.&]~w"n, |`d@[S$n̒놵4 d쨪w,* _K 1-= >43} }.1w* "㧖%iiXDNڀ0ܦgMۛm{A^x̬/ayzs[nB ?j`pHunxSa8^h,5m{ZVߠߖ5tXwIu#1w#UFHGPy:l~~?<7zXo^c.n}z ` 2!Xa{/g>r8v/ti`1ϥl|sdbas?RIFi+tc=2] ѩ!Z=@=ln0DžJ3Xƪ+Hfe5³m.85"Z*VZ`*Z嗑չqv< Z\(%4Pєuj p!4@ۮ6 nj*CEױ5+67ga 1ۦ`9'7zD>TK n⫩_ֻVeQO3ժ 27F`㖸#sZx2ap@<]+Zy\b/XJHѰSlƊ ob2H1zjr8mui+r2Ϧ3ҥ. $)>UFy.WaE\ZYǮN"ˡE20<_$ M FƠ_gFj%켑z~ :!H>X+L;-LFf2$:#1`],PUDalk3 Q7&=-WPƯBR2i$&lqk A$2 K/p5YV:, -P==,tEHv0tĴUKftyu VYlWg3ę&a>&Y2@ގ|YFDpy>O"Ѱ$yb18 +s<"]1Uͯ.l-`,TJWIc;jF.E}ufAk[RY(lxbh8],. *a#<Ut:NEM8s:Vl\8ZjM;\|6<,e2dW4ث bMCeu,N 2ܿbV26qEeYY$5)wxgYV;.=3Ś'M!FX)P᥌Ϟ> LT+W,UPlWUUM-e]=۴5Q4+$eilln@.jºZgH;ifbM~2ڳ&J9ޞulތ^(E=1QVm v>[I[N–daf6{_4a\٦X{sLJ[c8#>a=@z v hcLJx+>(~,~:y ㆡ/HU4'KGesSTLM;FX/v}>}1P{s%3q-Jf_,.GKYuds':Hv89Ne~ ($mp?,dAMb9ytG 3bS8MOڢjQRW$*{w\OۮiKq˖;r/dutYuM5YF$L~i_$8s6h|N◃8**:i)u4ʐ#| G2嚎e, %EFv :$x7aU9$fimlLRg;vN@p ڥ[2hTK-arwĊq9 ̲XֲDV+ Qk7YSѣ3 (>#ydL#t*ֵ%"̓1NA 6wy#kj~"̳JjWX $Y A;y`:W=K$Q$FcNX21bBx(j#=!D;q^kpOMRHЎԩ؛;ヸ櫆Z'U&z}k?g@&kKM)۸y)!mrb8\-|ᢇ RBS16 w;msW {VHN=ݿ<꿇^U'&RA&BoycKaޘѲ#XcE$Ӻow]1nqTʮZ~~;b_UUM!:Pf~%VK1ZT6kp _gZ+o-D3HC0k qgp*x'HfI5I6m4vNuugnwI.gTpƌbVǞ( uL#`Ms0u<0H/E`7Ixk3I{I `T0'68R aO'312`W XIMFdQQ!䑣z A#PEϖlWA=_O0-|d<@J&*܄mauyu|uSSHLe207'_^ +,qjJz,TD\oKƙFY_-Feb[%iXc pN;ܟ\,5Nk`".U^o P*E Ea=8BV;FkpDUÚiv(fyr'}{")k'/2SR9kYP^n^sS Y{x=o#x{488XսQvBŜ5ʮjOsOWWEl%HΒ wInV":sf\). $N6P0QJF4=6ĖA_9L+*I刷6Ԅ6` 82<#К Ut߮$-wfrh6+! IYe $m*\'<~ZvDD~}LqTDԌPw>xpV7| `b L9@),.x\#8DBQ6ֲjbZ u1pGqWG@]6[I\ys4TEk_`܁bC*e!X6c nC @îWdBw}14u\".@G{<_ZV>ڜmr@O˩Жq2?\KK)l"4JI4g=1 n| 9WdTx^X5` ;_sOQ~ <0 0 '.M2&v o/-Jzf R~mCKQc%SKvV }u>7ӟo?,S驙cCW<_ 6Z"^] (ʪ(uW.Wao_ OSdk_ Rf4e'h]9DkU٩xf哽aDm񘽗xݝ2I3H[qmܺ$r.Gap )r8yW~WW y+hғSc<$D̞W燜{&5Rm._T|W: 36 Jn?\QQw_24F{.t`$Ӱvæ 5CjZ;fo/soDhd[[۞3A,o|/}*V(> ]{ @;ߗL( o|utrCx…农?_OOfd7$|mmFlFk 76{I*s "x#RI/ٙ($m8ʧOԧE݉qlp[]e[G68jN1Gjk_剚,N!b  q_PkUDr{H. "ɩj\1stcO5e7khX= jhz ٔ2@ g=G1}I+h4ZYȺ;+2ȣ掺BY(];&n |^#\ղ\U4:eU6,;+ㇱ:or0OFWف[ A*c|Og&OWRS /̯=g]ZH.. ǰi,Ø6b3fDФl>fsդ|@L2? c|*:D⫱P@?A|PgH} %x+BFL9r:ܚߴ4TܮA<BiP/g vj߭H`.}`W꣖V Nyu ii"ybJ>(iiBt>ۮܦ$ V#tT UOgPrȡVhe+rq}$[{ ωUSGP)E܃0F|wR"/̡]m5F nG`u1JfcŁQI2X>;)sOW=<$-E2$#l00owL~%9}EPaݔ}BGSq r&a"L~ÑЏ fYfcfPU^euO0p)k#"xF !@{=EUo ʫnony>gNY-?FAT];:u~^- wӨyCYu5e`K|WC=3Α)c l5X\ ""]A /2<|v $$d^wWZxʟ-3M5= :}l~gٻ]%3u9Z6r*vOF<0 0ڨdf6[s,; Z(_+//zy(ZІ|P"o_zh^u?{c)e$.y~tYBQYڜ'5B4|ō,=ZIQ׵S v;06S}ΣoS_aޱ A>c [ Fٓv L,-p68mLamxIǦ lH_+(V+Fc5!`a/k3_nY`0K2#%MvWb<6"FQo,kڪG17:Fǐ bVڈө~0bY x accK2 ؐj o; V_8"˻%VblA; (B!3"*ef*Yui}w<,IP;76Ygvj|;z:`+I*ėB6oGM(IQ#l^˟" =p1 k(&at'Fj.Kt%{)H c&~/vw؊u6yƿ<% /3Q).I")f' 2lQ%PCK:^2W17 pNJnF~nXk y`5(U۳Wx6_>٢Qάkّ ya*/ktDžtt4 EH0-6R<6;)ߨ0e*6F ܜ6N@,`!T~)(w;^Uprw(m攵EBX F ኙ>gUVI~ MnqH)sEuv-i\y_h,05OYrw>MqrORk3LMj976:o?0ٌm&|;V\~:;^n*:!(6mLg?ckbTB[IjMO{ZU/tQq:Uq5(͞qMoo+}d'm)W 8e<J [Oi{m[+Пo6QUQQ1 .ڻXחذnvrHRg1!mU\lÈq%zPlV&lc0ޤiI׍43=;[b {[dKvDy@!4mA?mWki7m+> TIw46?< j\ImxNdQ9) xkԳZg;f+ 7)"sBrk/EHi~J <==Uߟv7"h$)`f/t{;Uygփ%>4^KqŸY~Fp )s".|&ߵSuNjR|l\h#f!(Co[.\ܬg\7ɀ񂙚AȿJԺX.rBz^+'xiUD1D]A-۴&[ue9e[{fTImwl"6)zPqQHy>BKtѶ$J9rUͯ&Ėy/=Ҝ:ۄ% rCQKp4F.FwF,G\lb92monDZGěc] ^=pmzl1~Mc"ݥ)G9E?io{2-+JЯڃU 3>;3,DuU0EĶTZ]5%ȌlPVWOڂY+Mσ߭pe?+r vLI.] 4yoT>TGۢLzlx#m+LVq]aeT"U_J^)C{x1˯JEZ`H)1-pcjNUUDʪr=kɺ<6 Q9eyA1[:8.+c1YT^An/49gz%3rj7+۲c-Dl6\$/4E_4c0nۆnlQT=9+ʬ4uT{z'jlkopRޱ{pc)Һj~ce-Ep[qtHQ}w_$Ϻ"G=HUDW*>E ݣKIQ55u# -yyW>vm}a|7VR:l|?. K w6     Causes of Errors  0Stress = poor performance Markers of stress: Cynical outlook Deterioration in appearance Increasingly working to the book Irritability Loss of confidence Missed deadlines Mistakes Reduction in quality of work Social withdrawal Cuthell T (2004) De-stressing the workforce Occupational Health 56(1); 14-16`-PPN P-,   F  Error Reduction and Avoidance   bCultural change Stop asking  who s to blame and ask  why did this happen System-wide approach Root cause analysis Learning from mistakes Strengthen professional accountability&   Error Reduction and Avoidance Leadership Support and empowerment Team building Supervision & role modelling Education Competence for practice Faculty of Emergency Nursing; Skills for Health Unit Shared education ` C ^ C ^  Error Reduction and Avoidance zStreamlining Simplify systems and processes Best practice, benchmarking Use of protocols, flowcharts, pathways Repackaging& n n Error Reduction and Avoidance nITM Forced functions Decision support Drug calculations Data collection and feedback on errors  To err is human& but to really foul things up takes a computer (Farmers Almanac 1978)0\XError reduction in practiceTakes time Reasons for failure (Ruchlin et al 2004): Fail to establish sense of urgency Not building a strong enough guiding team Lacking a vision Under-communicating the vision05}}  Error reduction in practiceTReasons for failure: Failing to remove obstacles No systematic planning or short term wins Declaring victory too soon Not anchoring changes in the corporation s culture Ruchlin HS et al (2004) The role of leadership in instilling a culture of safety. Journal of Healthcare Management 49(1);47-58 vZZ ZZS   z!Error reduction in practiceLeeds: Interventional Assessment Teams Standardized approach to assessment Rapid identification of key needs and early intervention Flowcharts and pathways to guide decision making and choice of interventions Identification of patients for early referral/admission/discharge Preparation of staff  competence Supervision by experienced staff System wide change  not quite!@ Q Q"Error reduction in practiceLeeds Nurse-led DVT and Cellulitis management on Clinical Decisions Units Protocolised management Risk assessment tool Preparation of staff  competence, supervision Review of practice  feedback of errors Audit  improved consistency of management and documentation.:DD#SummaryErrors happen for complex reasons Error reporting needs a common language System wide approach Error reduction takes time Stop blaming /l   $ % & '   ` 3ffffƍ` 3f3fff̙3ff̙` ______` 3f33>?" dZ@$?lKd@   l@  P`lA n?" dd@   @@``PT   @ ` `p>>   ,1 (  ,<T  , "h , s *"h , s *"" , <dG0*p` >  " , 6D @ 3  T Click to edit Master title style! !"$ , 0$ @ 3  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S" ,  `ij ?? @ 3  G*" "  ,  `D ?? p   3  G*" "  ,  `䴘 ??5 3  K*"" "^T   , "n"  , 0G"r  ,B T??h , C 2Anewtrustlogo`"B , s *޽h ? 3f3fff̙3ff̙ Capsulesb      0 0(  0 0 6$4@  >  "" 0 <Ĉ4G0*pp  >  " 0 <4 4   3  W#Click to edit Master subtitle style$ $"lT    0   "n" 0B 0G R "r 0 T??L  " 0  `4 ?? @  3  K*"" "  0  `ą4 ??    3  G*" "  0  `d4 ??x 3  K*"" "   0  `4 ??NnR 3  T Click to edit Master title style! !"h  0 C 2Anewtrustlogo`"B 0 s *޽h ? 3f3fff̙3ff̙ 0 P4.(  4 4 04 O3  4 Y*  4 0D~4  3 4 [* d 4 c $ ?po  4 4 04 e @1 4 RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S 4 6d4 O  4 Y*  4 6$4   4 [* H 4 0whg ? ̙3380___PPT10.  @4(    0D4 O3  4 =*   0~4  3 4 ?*   6$4 O  4 =*   64   4 ?* H  0whg ? ̙33   0(  x  c $}4 0NnR 3  x  c $404   4 H  0޽h ? xiPfr}OA333   p<$(  <r < S d,@  4 r < S ,@ 4 H < 0޽h ? 3f3fff̙3ff̙$   @$(  @r @ S ,@  4 r @ S $,@ 4 H @ 0޽h ? 3f3fff̙3ff̙80___PPT10.ణ\$   L$(  Lr L S ,@  ' r L S ,@ ' H L 0޽h ? 3f3fff̙3ff̙80___PPT10.@(}   T$(  Tr T S ,@  ' r T S ,@ ' H T 0޽h ? 3f3fff̙3ff̙___PPT10i.`ߧ+D=' = @B +   $(  r  S ',@  ' r  S 4',@ ' H  0޽h ? 3f3fff̙3ff̙   $(  r  S ',@  ' r  S t',@ ' H  0޽h ? 3f3fff̙3ff̙$   0\$(  \r \ S ԁ',@  ' r \ S ~',@ ' H \ 0޽h ? 3f3fff̙3ff̙80___PPT10. PU   P$(  r  S Ԅ',@  ' r  S ',@ ' H  0޽h ? 3f3fff̙3ff̙   >6pd(  dr d S T',@   x d c $|',@    d \A ,subway  H d 0޽h ? 3f3fff̙3ff̙80___PPT10. @d$   l$(  lr l S ',@  4 r l S ',@ 4 H l 0޽h ? 3f3fff̙3ff̙80___PPT10.7}   x$(  xr x S t,@  4 r x S T,@ 4 H x 0޽h ? 3f3fff̙3ff̙___PPT10i.+D=' = @B +$   |$(  |r | S ,@  4 r | S ,@ 4 H | 0޽h ? 3f3fff̙3ff̙80___PPT10.   $(  r  S ,@  4 r  S ,@ 4 H  0޽h ? 3f3fff̙3ff̙   $(  r  S ,@   r  S ,@  H  0޽h ? 3f3fff̙3ff̙   $(  r  S K,@   r  S K,@  H  0޽h ? 3f3fff̙3ff̙   $(  r  S L,@   r  S M,@  H  0޽h ? 3f3fff̙3ff̙    $(  r  S 4N,@   r  S N,@  H  0޽h ? 3f3fff̙3ff̙   0$(  r  S TO,@   r  S O,@  H  0޽h ? 3f3fff̙3ff̙   @$(  r  S P,@   r  S tP,@  H  0޽h ? 3f3fff̙3ff̙   P$(  r  S Q,@   r  S Q,@  H  0޽h ? 3f3fff̙3ff̙ 0 `8*(  8^ 8 S 4po   4 8 c $4e @1  4   H 8 0whg ? ̙33; 0 DK(  D^ D S 4po   4 D c $4e @1  4 ATalk about error prevalence, how widespread the problem is. Discuss why errors occur in nursing, looking at whole system problems, and contributory factors such as staffing levels, workload, preparation for role, and stress. Examine value of reporting errors, and take a look at a taxonomy of errors to help standardize reporting. Look at strategies to reduce errors in emergency nursing, both internationally and nationally, and then offer a brief overview of some strategies in use locally to help minimise errors.     H D 0whg ? ̙3380___PPT10.r 0 NFH(  H^ H S 4po   '@ H c $4e @1  ' What s the size of the problem? Report from the Institute of Medicine in USA reveals that there are between 44,000 and 98,000 deaths per year from medical errors. The report highlights that this is more deaths than from RTAs, breast cancer or AIDS. It also emphasizes that higher error rates with more serious consequences are likely in ICU, OR & A&E. The total cost, including additional care, lost income and disability payments, is $17-$29 billion per year.    H H 0whg ? ̙3380___PPT10.@QN 0 ZRP(  P^ P S 4po   'L P c $4e @1  ' ~In this country the scale of the problem is less clear. The DoH published a guide to improving standards and reducing errors in the NHS. Identified 850,000 adverse events each year, and 400 people die or are seriously injured through events involving medical devices. There is a cost to the NHS of 2 billion in additional hospital stays, and of 400 million in negligence payments.Z%  ;  @ H P 0whg ? ̙3380___PPT10.@>$ 0 X4(  X^ X S 4po   ' X c $4e @1  ' *Errors attributable directly to nursing are difficult to quantify. In the US preventable medication errors, in which nursing plays an important part, are reported in 2 out of every 100 admissions, and annually there are 7000 deaths caused by medication errors alone. In the UK reports by the Health Services Ombudsman in 2002 and 2003 demonstrate an increase in the reports of nursing errors. Whether this represents and increase in the number of errors or ore people willing to report errors is uncertain. More worrying is the observation by John Tingle that the common errors such as deficiencies in documentation, and failing to have written policies, protocols and guidelines, are occurring repeatedly, without any evidence of learning from one another s mistakes.  H X 0whg ? ̙3380___PPT10.`` 0 @`(  `^ ` S 4po   ' ` c $'4e @1  ' nIn trying to identify to key causes of errors in nursing various authors use differing terms for the origins of errors. These include  systems errors and  human errors , or  macro and  micro views. However it is seldom easy to separate out causes of error in this way. One thing that many authors agree on is that errors are seldom caused by one person or factor, that they are the result of a culmination of events and circumstances.  H ` 0whg ? ̙3380___PPT10. P2B  0   pR (  p^ p S 4po     p c $'4e @1   H  Whatever the analytical approach, the clear risk factors are demand and manpower. In Leeds we are continuing to see increasing numbers of patients presenting at A&E. Coupled to this are the practices of, until very recently, all admissions and all specialty referrals coming through A&E. All of these patients are expected to be managed and cared for within the four hour target by A&E staff. Some days feel like this  the Tokyo underground, where someone was employed to ensure the system was full to capacity, regardless of the effects on the users. I think that on busy days the four hour targets are like a UTI for A&E departments. First you get the sense of urgency as things build up, then frequency as you dash in and out of cubicles. Then you experience the difficulty because there s an obstruction further down the system. And the worst thing is that you know it s going to recur. The alteration in GP OOH contracts are likely to increase the burden on A&E departments in the short and medium term. And alterations to Junior doctors hours and training will have repercussions for the number and experience of staff available to see patients.Z  H p 0whg ? ̙3380___PPT10.5 0   t" (  t^ t S 4po   4  t c $T'4e @1  4   Manpower is the other part of the equation in demand and capacity. Despite the governments best intentions, recruitment remains a problem. The NHS is perceived as an unpopular employer, failing to look after its employees. Nursing as a career is perceived by young people as rewarding but stressful and still poorly rewarded. This creates difficulty in all areas of nursing, and particularly in those fields that are high pressured and fast moving. There is little slack in the system to cope with shortages and sickness, and shifts are frequently filled by temporary or agency staff that may not have experience and knowledge relevant to the field that they re working in. They may not know the systems and processes in place in the A&E department for dealing with given patient conditions. This places an added stress on permanent staff, who face the dilemma of either trying supervise several temporary staff as well as junior staff, or of trying to do as much of the specialist work as possible themselves. Both scenarios are potential precursors to errors. Tarnow-Mordi and colleagues demonstrated a link between excessive demand in ICU and negative outcome for patients. More specifically they demonstrated that when the number of patients exceeded the workload capacity of the nurses then patients died. It seems not unreasonable to extrapolate the principles of this study to A&E, and to predict that when capacity exceeds demand then errors will result and patient care will suffer.Z6(     H t 0whg ? ̙3380___PPT10.  0 `d(  ^  S 4po   '  c $4|'4e @1  ' ZFBeverly Henry highlights the complexity of error causation in nursing.H  0whg ? ̙33 0 LD`(  ^  S 4po   >  c $R4e @1   Errors in nursing occur because nurses are imperfect creatures working within imperfect systems. The challenge is recognising and accepting that perfection really is unattainable, although the goal is laudable. Developing and sustaining a culture built on safety can only occur after a reporting culture and a just culture have been established. To do this we must first change the belief that medicine and nursing should be error-free practices.H  0whg ? ̙33$  0   t (  ^  S 4po   '   c ${'4e @1  ' j 4 If we are to understand the nature and causation of errors we must share our mistakes so that learning can occur across the system. To do this effectively there must be a common language for error reporting. In the UK the DOH, in Building a Safer NHS, has provided guidance on common definitions of adverse events and the kinds of questions to ask after errors occur. In the USA the Practice Breakdown Research Advisory Panel reviews all reports of nursing errors made to State Boards, and has produced a taxonomy of nursing errors to aid future classification. Lack of attentiveness  failing to pay attention to clinical condition. May be missed predictable complications, such as hypotensive episodes during thrombolysis, or early recognition of unpredictable conditions, such as cardiac arrest in the previously stable patient. Lack of agency/fiduciary concern  like our duty of care. Such errors would include failing to highlight an erroneous medical order, or failing to heed a patient or families request for help. Inadequate judgement concerns clinical judgement, and errors occur because of inadequate assessment, care based on ritual rather than logical judgement, unwarranted interventions such as too much analgesia, and unreasonable expectations of lesser-trained staff. Medication errors are one of the largest sources of adverse events, and causes are multitude, such as wrong dose, drug, time, rate, patient.. H  0whg ? ̙33 0  g(  ^  S 4po   '  c $T}'4e @1  ' ]ILack of intervention may follow lack of attentiveness, such as failing to check on patients conditions or respond to adverse signs. Lack of prevention can be around breach of infection control measures or lack of prevention of hazards of immobility Missed or mistaken instructions and documentation errors speak for themselves.H  0whg ? ̙33*  0 z(  ^  S 4po   4  c $44e @1  4 p\Cultural change requires good leadership to facilitate and demonstrate a culture that fosters support and empowerment of staff. Leaders in safety-focused organisations actively build teams in which there is recognition for one another's knowledge and skills, and in which asking for help and admitting strengths and weaknesses are encouraged. Demonstrating this means being visible and active in the role, working alongside less experienced staff to provide supervision and expertise. Education  requires investment, to ensure nurses at all levels are competent for practice. Fen/SKHU Value of shared education between professional groups  shared language and goals of management.H  0whg ? ̙33rUO8EWYO[;]@g_ag$ln qsjuwydf{k}WC/:{UpK(Oh+'0Z hp $ D P \hpPowerPoint Presentation McMastert PNC:\Program Files\Microsoft Office\Templates\Presentation Designs\Capsules.pot\paul illingworthMic123Microsoft PowerPointoso@@F@ bJ@ +[  G@YoM  ,'& &&#TNPPp0D & TNPP &&TNPP    --- !---̙--- !--- |w|wgw - &Hhj2--X$*hijptyeYPJIHIJPYet(.0000.+(<KW`fhhhf`WK<y+pjih--& &}}#&}e%-3f-$ccc#c#}#}#}}--&&b%-3f-$ puy| }|yu"p#b#b--&&&& & {& &'C .(8O  ÷뺳ɾǾΙú轵»uɕ~bƱҞzﾪյ󧛏ߴϾĦƭînŧn ֜oɶƫ{ӹЬ˻󡔆㶠Ƿ°ǵǮŸyĥʬֺȦӓ~j˵{hѻnrz̳𨝊ǒpѹ䲝yrV̵ֶΙy󼪝ñ̾ãƲ־˼ȽȡnϿľŢ̄|||SSS111aaa+++444>?Addd777###ǿŨԲֱҭկⱏⱏⱏⱏⱏⱏⱏⱏگۯݯ߰ᰎ䰍汋汋ᶗߴܱگگܱߴᶗ絕峓ⰐஎஎⰐ峓絕񟟟ttt𣣣QQQEEEژhhh[[[PPPjjjUUUWWWOOOaaajjjMMMTTTWWW|||UUUUUU|||jjj[[[fffEEEޙĊLLL,,,̢󸸸SSS^^^```GGGFECwwwZ]``djtsq]\Z񫪨YXVXWULLLb\aůgLX0b4c2_.a0e*e*e*e*e*e*e*e*e.e.e-e+e*e(e'f&o7k3d,`(`(d,k3o7o5k1d*`&`&d*k1o5 MMM|||NNN666ZZZMMMLLL TTTeee$$$,,,sssgggJJJ }}}]]]aaa^^^{{{NNN###NNNUUUwwwQQQtttUUUjjjkkk((($$$bbbdddWWW$$$zzz333fffxxxzzz eeemmmsssAAAddd...,,,@@@ccc{{{lllݳ---@@@mmm|||nknȲsPΕl:ji_&Գ˰|j3ۣii)n#e)ǢÕkAũδqo;a%r3~>  !!!444[[[lll@@@ ***lllpppFFFRRRbbb]]]mmm444___ 888'''???fff???IIIBBBNNNMMM===ooo<<<===\\\ ӹsT箇[n&j(Q˞s@Ȯm-f^۬ӮsLҪ~LS̔SCCC~~~kkk&&&$$$???((({{{~~~@@@EEEnnniiiRRR lll...###/// |||NNNHHH'''eeeTTTTTT___LLLcccGGG^^^񵵵*'*ӷc@ٽš}g(b(˨佛uIêҲr8fh'֝jН_ƚɛܽ׵γݹ[&z: mmmvvvyyy555EEE<<>>΃fffWWWCCCnnnoooԷ~O#߸ջb(c/ͫӞUѮwFb"f(I驔ik0w4u2d#jQQQVVV%%%""")))###]]]III555......111WWW&&&+++HHHbbb ___&&& ggg MMMkkk777(((MMM333///***AAA 000888mmmsssڡ:::$$$DDDWWW]]][[[///pppkkk>>>žSΣlڴj2yMᴚplઁ\a.\'^*ؿo+p!u&j"Y(f@ھzH@+++aaa::: QQQ"""EEE888000+++RRRTTT???333NNNfffZZZRRRFFF///)))PPP??? KKKIII111LLLWWW>>>---888;;;{{{ppp EEEaaa###777kkk;;;###!!!___:::www~~~!!!NNNGGG:::GGG???MMM###oooRRRIIIbbbFFF\\\mmmTTTbbbyyy]]]XXXAAAgggvvvRRRkkk񌌌...OLOqnqƟ]QΎtDzкʷoUйʥȡy vЩo.Zf z>ơyǤӬj3q1""",,,ƥؕНđ$$$ǍiiiWWWӿ555ϠВŅFFF<<̰KV\%ÐdnjvQܼi$fh'NjqOɳqIԸXn"r.ɖҬ޾ܳȑ:hm,̋SѠۨR’y8r[×\ު㱖i2r7̡dΦݹTҽf/d!Ql@^;eBa<^,[]^^)`3a4k>}Me8sEn _PID_GUIDAN{8C18EA2B-78BE-11D8-B242-004081094556}(_paul illingworth  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root EntrydO)Picturesh<Current UserSummaryInformation(ZPowerPoint DocumentcBcc(cBccDocumentSummaryInformationc8Bccccccccccccccccccccccccc