R E V I E W S & A N A LY S E S Health Literacy and Patient Safety Events Lea Anne Gardner, PhD, RN INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority Helping patients understand healthcare information and instructions is pivotal to engaging patients to improve their own health and safety. The challenge in communi- ABSTRACT cating complicated and sometimes evolving healthcare information is in the presenter’s ability to deliver the information in a clear yet concise manner. Learning to read Structuring and presenting healthcare and speak healthcare terminology is akin to learning a foreign language. Acronyms, information that aligns with a patient’s abbreviations, and Latin-based words are often used to represent complex concepts. level of understanding can help Individuals unfamiliar with medical terms frequently struggle to understand and make patients achieve optimal outcomes. The decisions based on information presented to them. Analysts from the Pennsylvania Pennsylvania Patient Safety Authority Patient Safety Authority identified event reports in which the patient’s misunderstand- is participating in a statewide health ing of healthcare instructions or information adversely impacted the patient’s care. literacy initiative focused on providing strategies to healthcare providers that Communication gaps are not new to healthcare and can contribute to Serious Events, help patients understand and engage including permanent loss of function and even death.1 Health literacy, the ability to in their medical care. A search of the comprehend healthcare information, goes beyond reading and writing, and includes Pennsylvania Patient Safety Reporting listening, speaking, and numeracy (i.e., use of math skills and reasoning for decision- System identified 265 potential health making in everyday situations) in order to make informed healthcare choices.2 literacy–related event reports in which In 2010, the Health Care Improvement Foundation and Thomas Jefferson University patients misunderstood or did not com- and Hospitals started a health literacy initiative funded by the Pennsylvania prehend healthcare instructions provided Department of Health. This program, Southeastern Pennsylvania Regional to them by healthcare clinicians. The Enhancements Addressing Disconnects in Cardiovascular Health Communication most frequent outcomes of patients mis- (SEPA-READS), began as a regional effort in Southeastern Pennsylvania and initially understanding instructions or information focused on older adults, age 50 or older, with cardiovascular disease. The SEPA- were delayed or cancelled procedures, READS program has since expanded across the Commonwealth and helped spur surgeries, treatments, or tests; or patients the formation of the Pennsylvania Health Literacy Coalition.3 In December 2015, leaving without being seen. Verbal com- Authority staff attended a train-the-trainer program, “Communicating to Connect: munication strategies such as “teach Strategies to Improve Health Literacy.” This program taught Authority staff about back” and “Ask Me 3®” programs and health literacy principles and provided methods to disseminate this information among written strategies address opportunities Pennsylvania healthcare facilities to improve patient comprehension of healthcare identified in the event reports and may information. To better understand the impact of health literacy on patient care in help improve patient understanding and Pennsylvania, Authority analysts searched the Pennsylvania Patient Safety Reporting engagement in their care. (Pa Patient Saf System (PA-PSRS) database to identify potential health literacy–related event reports. Advis 2016 Jun;13[2]:58-65.) METHODS Analysts queried the PA-PSRS database, searching the event narratives and recommendation data fields using the following keywords and phrases: “misunderstood,” “misunderstand,” “comprehend,” “did not understand,” and “did not follow directions;” the query was for the 10-year time period of January 2005 through December 2014. Analysts read event report narratives to identify potential health literacy–related event reports (i.e., situations in which patients either misunderstood or did not comprehend healthcare instructions or informa- tion provided to them by healthcare clinicians). Situations in which healthcare workers misunderstood instructions or orders were excluded. Potential health literacy–related event reports were analyzed according to patient age and harm score.* Scan this code Event report narratives and PA-PSRS data fields labeled “contributing factors” (e.g., with your mobile patient not understanding) and “remedy factors” (i.e., what was done to remedy the device’s QR reader to access the Authority's toolkit * The Pennsylvania Patient Safety Authority Harm Score Taxonomy is available online at http:// on this topic. patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2015/mar;12(1)/PublishingImages/ taxonomy.pdf. Page 58 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority situation) were further analyzed to identify majority of events (48.3%, n = 128 of 265) most frequently reported explanation for patient outcomes, event explanations (e.g., were reported as a harm score C followed a misunderstanding. The most frequently preoperative instructions not followed), by the next harm score category D (27.9%, reported contributing factor was patient contributing factors, and remedies. n = 74). not understanding (80.5%, n = 62 of 77); Event reports describing patients with Outcomes, explanations, contributing lack of patient compliance, the second cognitive impairment were also found and factors, and remedies. Seven outcomes, most frequently reported contributing analyzed separately to identify outcomes five explanations, four patient-related factor, often results from lack of patient specific to this subgroup. contributing factors, and one patient- understanding.4 Talking to the patient/ related remedy were identified (Table 1). family was the only patient-related remedy Outcomes were identified in all but one identified (n = 71). RESULTS Patient-Related Event Reports report. The most frequently reported Cognitive impairment. A subgroup of 75 outcome was a delayed or cancelled pro- event reports (28.3%) was identified that Analysts identified 265 potential health cedure/surgery/treatment/test or the described patients who were confused, literacy-related event reports in which patient leaving without being seen (33.7%, had cognitive disorders (e.g., Alzheimer’s patients misunderstood or failed to n = 89 of 265), followed by patient falls disease, dementia), psychiatric disorders, understand instructions or information (30.7%, n = 81). Fewer than half of the or an inability to comprehend instruc- provided by healthcare clinicians. event reports identified an explanation tions (e.g., traumatic brain injuries). Patient age. The largest number of event (35.8%, n = 95 of 265), contributing fac- Patients in this subgroup experienced the reports (16.6%, n = 44 of 265) involved tor (29.0%, n =77), or remedy (26.8%, n outcomes shown in Table 2. patients 51 to 60 years old. See Figure 1 = 71).* Patients not following preoperative for the age distribution from newborns to instructions (54.6%, n = 53 of 97) was the Examples of Patient 94 years. Misunderstandings Harm score. Ten (3.8%) events were * Several event reports identified more than The following are de-identified PA-PSRS reported as Serious Events; harm scores one explanation or contributing factor for event narratives.† were E and F. There were no event reports patients not following a healthcare worker’s directions. Delayed or Cancelled Procedure/Surgery/ with the harm scores G, H, or I. The Treatment/Test Even though the patient had pre- Figure 1. Potential Health Literacy–Related Events Involving Patient Misunderstanding op instructions explained to her as reported through Pennsylvania Patient Safety Reporting System, By Patient Age yesterday, she obviously did not (Years), 2005 through 2014 (N = 265) understand. The nurse explained the instructions several times and the NUMBER OF EVENTS patient’s husband said he could stay 50 and would be able to take a taxi 44 45 home with his wife, the patient. This 40 [action] did not transpire and the 36 patient’s procedure had to be can- 35 31 30 29 celled on the day of surgery. 30 26 25 Patient was to have an outpatient 25 MRI with sedation. The patient 20 17 16 had concerns about sedation. 15 Investigation with involved staff 10 6 revealed that detailed explanations 5 5 were given to the patient. The patient was extremely anxious about the 0 10 e 20 30 40 50 60 70 80 90 94 ag to to to to to to to to to to ed n 11 21 31 41 51 61 71 81 91 tifi or † The details of the PA-PSRS event narratives en b MS16417 ew in this article have been modified to preserve id PATIENT AGE (YEARS) N Un confidentiality. Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 59 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S procedure. The patient left without family had left, the patient staggered in a chair. The patient did not under- sedation or the test being performed. out of the room and fell in the hall- stand what was told to her. Patient Falls way. No injury noted. The patient was found by staff in the bathroom. was immediately raised up to his feet Patient has right hemiparesis. Patient The patient had been to the bath- and assisted back into his room. room without assistance. The patient was instructed not to get up without at times did not understand what Patient stated several times that she assist. Patient dropped her glasses on was being said. Just prior to being wanted to get into bed. She was told the floor, and in an attempt to get admitted to the floor, and after that her physician ordered her to sit them, she fell. Table 1. Potential Health Literacy-Related Event Outcomes, Explanations, Contributing Factors, and Remedies, as Reported through Pennsylvania Patient Safety Reporting System, January 2005 through December 2014 (N = 265) NO. OF EVENT % OF EVENT OUTCOMES REPORTS REPORTS Delayed or cancelled procedure/surgery/treatment/test or patient 89 33.7 left before being seen Fall 81 30.7 Medication error 31 11.7 Premature removal of pulmonary, gastric, or peripheral central catheters 19 7.2 Aggression by patient or family 11 4.2 Wrong procedure/site 4 1.5 Miscellaneous (e.g., skin tears, patients leaving unit, removed dressing) 29 11.0 Total 264* 100 EXPLANATIONS † Preoperative instructions not followed 53 55.8 Language barrier 15 15.8 Discharge instructions not followed 13 13.7 Consent issue 9 9.5 Change in mental/medical status 8 8.4 Total 95§ 100 CONTRIBUTING FACTORS † Lack of patient understanding 62 80.5 Lack of patient compliance‡ 37 48.1 Lack of family cooperation 7 9.1 Language barrier 4 5.2 Total 77§ 100 REMEDIES Information or explanation provided to patient or family 71 100 Total 71 100 * One event report did not identify an outcome. †  Explanations and contributing factors not reported on all reports. ‡ Lack of patient compliance is often a result of lack of patient understanding.4 §    More than one explanation or contributing factor was described in some reports. Page 60 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority Table 2. Cognitive Impairment-Related Outcomes, as reported through the Pennsylvania Patient Safety Reporting System, January 2005 through December 2014 (n = 264*) EVENT REPORTS SPECIFYING COGNITIVE IMPAIRMENT OUTCOMES (NO. OF EVENT REPORTS/TOTAL NO. OF EVENTS) Aggression-related incidents by patients or family 81.8% (9 of 11) Unplanned removal of tracheostomy, nasogastric, and 73.7% (14 of 19) gastric tubes Falls 44.4% (36 of 81) Miscellaneous issues (e.g., pressure ulcers) 20.7% (6 of 29) Delays or cancellations in procedures, surgery, treatments, 9.0% (8 of 89) or tests Medication errors 6.5% (2 of 31) Wrong procedure or site 0% (0 of 4) * One event report did not identify an outcome. Preoperative Instructions Not Followed be done, did not understand physi- easily measured, such as oral and written The patient told the doctor that he cian explanations… will have to wait communication skills, reading ability, and had taken his [medication] for the until tomorrow. familiarity with language, as well as back- past 3 days. The prescription was Extubations ground knowledge, such as biology, and written for postoperative use. The different cultural approaches to health Patient found pulling her [nasogas- care.5 patient misunderstood. The doctor tric] tube out. Patient repositioned explained to the patient the risk of and order received to replace tube. Almost one third (28.3%, n = 75 of continuing with the surgery due to Patient unable to comprehend the 265) of reported events in Pennsylvania the fact that he had been taking need to leave the tubes alone. involved patients with a cognitive impair- the [medication]. The patient and ment, and more than half (55.3%, surgeon agreed to cancel the surgery Patient was sitting up in the chair. n = 146 of 264) were patients age 51 or and surgery will be rescheduled. The When family entered the room, they older. Many factors influence a person’s patient was re-educated to not take noted the [patient’s] Foley catheter ability to process and understand health any medication prior to surgery. was completely removed. The patient care information. Individual factors may was in no distress… Patient in wrist include culture, language, emotion, age, The patient arrived for endoscopy. restraints due to mentally…unable to The patient misunderstood instruc- medications, previous exposure to the comprehend reason for tubes. health care system, cognitive impairment, tions and ate a sandwich two hours prior to arriving for the procedure. and general literacy, as well as acute DISCUSSION stresses such as fatigue and illness.2,5,6,7 The patient had a snack at 5:45 am. Healthcare system factors include the In the PA-PSRS events, oral communica- The parent misunderstood the NPO complex and often-contradictory nature tion issues, such as misunderstanding [nothing by mouth] instruction to stop of health care information, complicated oral instructions for preventing falls or solid food at midnight. The surgery technology, diverse manners of presenta- preoperative instructions, and written was delayed. tion (e.g., signs, directions,) and time communication issues, such as obtain- Consent Issues ing a consent for procedures or surgery, constraints.5 Although certain groups of are challenges faced by patients and patients (e.g., older adults, non-native Consent form for trigger finger release healthcare staff. A person’s level of health English speaking people) are at greater was blank on front page. [Staff] filled literacy is based on word recognition, risk of having a lower level of health liter- in trigger finger release for patient to reading comprehension, and numeracy.2 acy, it is difficult to determine a person’s read but was unable to obtain permis- Some aspects of health literacy are not level of health literacy by observation of sion. Patient not sure of procedure to how they look or speak.5,8 Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 61 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S The 2003 National Assessment of Adult Literacy (NAAL) categorized health HEALTH LITERACY LEVEL DESCRIPTIONS literacy into four levels based on standard- Below Basic—indicates no more than the most simple and concrete literacy skills, ized test scores. The NAAL health literacy such as not being literate in English or not locating easily identifiable information in results showed that 12% of adults had simple documents (e.g., charts or forms). proficient health literacy, 53% of adults had an intermediate health literacy level, Basic—indicates skills necessary to perform simple and everyday literacy activities, 22% of adults had a basic health literacy such as reading and understanding information in simple documents. level, and 14% had a below basic health Intermediate—indicates skills necessary to perform moderately challenging literacy literacy level.9 See "Health Literacy Level activities, such as locating information in dense, complex documents and making Descriptions" for further information. simple inferences about the information. The NAAL has been replaced by the Proficient—indicates skills necessary to perform more complex and challenging Program for the International Assessment literacy activities such as integrating, synthesizing, and analyzing multiple pieces of of Adult Competencies (PIAAC). The information located in complex documents. PIAAC was last administered in 2012 Source: Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s adults: results and yielded results similar to the NAAL, from the 2003 National Assessment of Adult Literacy (NCES 2006–483) [online]. 2006 [cited indicating that health literacy is relatively 2016 Feb 26] Washington, DC: U.S. Department of Education, National Center for Education; p. static at the population level.10 5. http://nces.ed.gov/pubs2006/2006483.pdf The NAAL assessed patient age, gender, race and ethnicity, language spoken before starting school, highest level of education, into everyday documents, such as consent understand instructions. Next, determine and poverty level. The results showed that, forms, and educational programs requires whether patients with limited decision- in general, women have a slightly higher time to develop, test, and implement.16-18 making capacity are incapable of making level of health literacy than men; more Obtaining informed consent involves their own decisions (e.g., giving informed adults age 65 or older had lower levels of more than obtaining a patient’s signa- consent) or whether there are periods health literacy than adults in any of the ture on a written consent form. It is an when they are lucid and able to actively younger age groups; Hispanic adults had interactive process between a patient and participate in their care.25,26 A patient’s lower average health literacy than adults physician that has two major elements: overall decision-making capacity will in any other race or ethnic group; adults a patient’s awareness and understanding drive the type of risk-reduction strategies who did not speak English before start- of a healthcare situation and treatment selected by healthcare staff. The follow- ing school had the lowest average health options, and their voluntary choice to ing risk-reduction strategies are useful to literacy level; and adults below the poverty act upon this information.19 A patient’s institute in patients who are unable to level had lower average health literacy than signature on a consent form does not comprehend instructions due to medical adults living above the poverty threshold.9 necessarily confirm that the patient or mental health conditions.7,25-31 understands the type of treatment he or Effects of Low Levels of she has authorized. Studies have shown Risk Reduction Strategies for Health Literacy that up to half of patients did not cor- Patients with Impaired Decision- Inadequate health literacy has been asso- rectly recall the risks of surgery and one Making Capabilities ciated with poorer health outcomes.11-14 third did not correctly recall the alterna- The following strategies can be used with Implementing plain language descriptions tives to the procedures after providing patients who have impaired decision- (e.g., replacing medical or technical terms informed consent.20-23 making capability: with words that people use in everyday conversations) during clinical encoun- Determining Health Literacy — Screen patients for cognitive ters and in healthcare documents can impairment Before implementing any health literacy help patients understand the complex strategies with patients, the first step is to — Engage family members or surrogate language used in healthcare.8,15,16 A plain ensure that the universal health literacy decision-makers in the patient’s care language agenda has been developed precautions are in place.24 Then staff can — Incorporate shared decision-making by the Centers for Disease Control and proceed to identify whether a patient has with other healthcare professionals Prevention and the federal government; a medical or mental health condition that who have cared for the patient however, application of plain language will impinge on the patient’s ability to Page 62 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority Recognizing Low Levels of and the National Patient Safety Foundation needs to know and needs to do (i.e., Health Literacy (NPSF) Ask Me 3® program can provide action oriented).8,15,24,35,39 Testing patients to determine their level feedback to healthcare clinicians about the — Communicate as if talking to a of health literacy can lead to shame and patient’s level of understanding.37,38 Written friend to show genuine interest.8,16,37 alienation.11,32-34 The literature suggests communication strategies are divided Non-Verbal Communication Skills close observation and asking certain according to common themes used to cre- ate the forms or instructions intended to — Face the patient when talking types of questions that can help identify inform patients. with him or her, make direct eye individuals with limited reading and contact, and use relaxed body comprehension skills.35 Patients with low language.15,24,35,37,39 health literacy may exhibit the following Risk Reduction Strategies behaviors:8,35,36 Oral Communication Written Communication — Make excuses when asked to read or The following risk reduction strategies can Written communication approaches can fill out forms, such as “I don’t have be implemented when communicating focus on principles that simplify written my glasses” or “I’ll read this when I verbally with a patient: instructions and forms that include: get home” Verbal Communication Techniques Document Suitability — Lift text close to their eyes, point to — Use teach back (or show me) — Use assessment tools to evaluate the the text with a finger while reading, method, which allows providers to overall suitability of materials, such or visually wander over the page confirm understanding by asking the as the Plain Language Grade level, without finding a central focus patient to demonstrate or explain, in Relevance, Interest, and Design — Provide incomplete medical history their own words, what they need to (Plain Language GRID), Suitability of or check items as “no” to avoid do.6,8,15,35-37 Assessment Materials (SAM), Patient follow-up questions — Encourage patients and families to Education Materials Assessment Tool — Listen carefully and take instructions ask questions and engage in their (PEMAT), and the Clear Communi- literally to avoid mistakes care. NPSF’s Ask Me 3® program is cation Index (CCI).15,16,24,39-42 — Identify medications based on color, an example of a patient education — Explain the purpose of documents size, and shape campaign that focuses on asking and keep the description simple (e.g., — Fail to comply with medication questions, as follows: (1) What is my one to two key objectives).8,35,40 regimens main problem? (2) What do I need — Provide clear messages; give the most — Frequently miss appointments to do? and (3) Why is it important important information first, describe for me to do this?8,15,35,38 what actions to take, and explain — Show signs of nervousness, confusion, frustration, and even indifference — Ask patients open-ended questions their importance.35 instead of questions that can be — Emphasize desired behaviors.35,40 — Avoid situations or withdraw when answered with a yes or no (e.g., — Highlight the positive message.35 complex learning is required “What questions do you have? — Pretest materials for the intended — Give incorrect answers when ques- instead of “Do you have any ques- tioned about what they have read audience.8,16,40,43 tions?” or “Do you understand?”)15,35 Keep in mind that if patients do not Document Content Verbal Communication Skills exhibit any of these behaviors, it is not — Write at a grade 4 to 6 level; use confirmation that they are health literate.5,8 — Talk slowly, use plain readability calculators such as the language.8,15-18,24,35-37,39 Simple Measure of Gobbledygook Addressing Health Literacy — Avoid medical jargon.8,15,18,24,35,37,39 (SMOG), Fry Graph Readability For- The majority of PA-PSRS events involved — Use a trained medical interpreter for mula, and Flesch-Kincaid readability patients with the capacity to make health- patients who have limited English tests (which is available in Microsoft care decisions. Yet these patients were faced proficiency.6,24,36 Word).6,8,15,35,40,44,45 with challenges in understanding oral and — Use videos, interactive computer pro- — Write in short, brief sentences (no or written communication instructions and grams, or pictures to accommodate more than 10 to 15 words).8,18,40 are the focus of the risk-reductions strate- different learning styles.8,24,35,36,40 — Limit paragraphs to three to five gies. Oral communication methods and — Keep number of points to three or sentences.8,16,18 programs such as the “teach back” method less to focus on what the person Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 63 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S — Use the word “must” to indicate — Leave right margin ragged so readers have contributed to events in ways that requirements.6,18 can easily track their location within were not recognized by staff. — Use active voice.8,16,18,24,40 the text.16,18,40,46 — Use plain language and words with — Create short lists (i.e., three to seven CONCLUSION one or two syllables.8,15,18,35,36,39,40 items) with bullets, not commas.16 Limited healthcare literacy can contribute — Avoid medical jargon, technical, or — Use no smaller than 12 point to delays or errors in treatment that can scientific language, and unnecessary font, ideally 14 point font; avoid lead to poor healthcare outcomes. The abbreviations and acronyms; if a com- italics.8,15-18,35,40,46 complexity of healthcare information that plex term cannot be avoided, clearly — Use a simple, clear font style; a healthcare clinicians use every day can be define what it means.6,8,15,16,18,35,39 sans serif font is generally recom- overwhelming for patients to comprehend — Use audience-appropriate images mended for viewing on screens and and assimilate. Clear communication of and diagrams to highlight key devices.16,40 healthcare information between health- messages.18,35 care clinicians and patients can improve LIMITATIONS patient understanding of the benefits and Document Format This retrospective review of reported risks and improve adherence with medi- — Keep design simple, with sharp events is limited by the information cal interventions, thereby increasing the contrast between text color and back- reported through PA-PSRS, including chance of better healthcare outcomes. ground paper color.46 the event descriptions and explanations. Achieving effective patient communica- — Include ample white space, use PA-PSRS does not have structured data tion requires implementation of universal appropriate space between lines of fields that identify health literacy events; precautions in a manner that meets the text (e.g., 1.2 to 1.5 spacing, and and the search terms used may not have health literacy needs of all patients. The leave at least ½ inch to 1 inch of encompassed all of the relevant descrip- written and verbal strategies identified white space around the margins and tions used in reported events. It is also in this article provide some initial steps between columns).8,16,18,40,46 possible that limited health literacy may that can help bridge communication gaps between clinicians and patients and lead to better informed patients. NOTES 1. Joint Commission 2015 Sentinel Event Washington DC: National Academy of 9. Kutner M, Greenberg E, Jin Y, et al. Data: root causes by event type 2004- Sciences [cited 2015 Jan 7]. https://iom. The health literacy of America’s 3Q 2015 [online]. [cited 2015 Dec 15]. nationalacademies.org/Reports/2004/ adults: results from the 2003 National http://www.jointcommission.org/ Health-Literacy-A-Prescription-to-End- Assessment of Adult Literacy (NCES assets/1/18/Root_Causes_Event_ Confusion.aspx 2006–483) [online]. 2006 [cited 2016 Type_2004-3Q_2015.pdf 6. 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[cited Quality. The SHARE approach—using the 2016 Mar 14]. http://www.ahrq.gov/ Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 65 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 2—June 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. 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