Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management

Detalhes bibliográficos
Autor(a) principal: Milena Pontes Portela Bezerra
Data de Publicação: 2011
Tipo de documento: Dissertação
Idioma: por
Título da fonte: Biblioteca Digital de Teses e Dissertações da UFC
Texto Completo: http://www.teses.ufc.br/tde_busca/arquivo.php?codArquivo=7401
Resumo: Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management. Author: Milena Pontes Portela Beserra. Supervisor: ProfÂ. Dr Marta Maria de FranÃa Fonteles. [Master degreeâs dissertation. Post Graduation in Pharmaceutical Science. Department of Pharmacy â Federal University of CearÃ]. BACKGROUND: Hospital Risk Management acts in the prevention, detection, control or eliminate risks that could cause harm to patients, in Brazil this concept was implemented in 2001 by the National Agency for Sanitary Surveillance (Anvisa), Ministry of Health with the project Sentinel Hospitals, and currently brings together nearly two hundred institutions. It consists basically of three pillars: pharmacovigilance, haemovigilance and technical surveillance. Indicators of results and adverse events are fundamental tools of quality by pointing out aspects of care that can be improved by making patient care without risks and failures, and therefore safer. In order to improve the quality of healthcare services in recent decades had the strength of the Hospital Accreditation Program consisting of external evaluation system that verifies the compliance of the structure and care processes with the adopted set of standards previously established. OBJECTIVES: To study adverse events suffered by hospitalized patients or that were related to drugs and related in a public secondary hospital accredited by National Accreditation Organization (ONA), in 2010, contextualizing the risk management approach in the hospital. METHODS: We conducted a retrospective documentary base at the Hospital General Dr. Waldemar Alcantara (HGWA) a survey of all reports of adverse drug reactions (ADRs), reactions to blood products and technical defects of materials, equipment and drugs, studying, and the risk management with a focus on pharmacovigilance, haemovigilance and technical surveillance, respectively. RESULTS AND DISCUSSION: There have been 271 events, with 166 (61.3%) RAM, 64 (23.6%) technical defects, 41 (15.1%) transfusion reactions. We found a higher number of RAM in patients with extreme age and use of antimicrobials, as well as previously reported. The main reported ADRs were dermatological and medical groups were more involved antimicrobials for systemic use. The main blood component was transfused red blood cells, is also a major cause of anemia, transfusion reactions and the main indication. The most transfusion reactions reported were fever (55.6%), dyspnea (8.9%) and urticaria (8.9%), these reactions were immediate in 92.7% of cases, they occurred in up to 24 hours after transfusion. Techniques have been reported 64 complaints of 40 different products, the main products cited were: saline 100 mL closed system (14.1%) and micropore tape (7.8%). Had the potential to cause direct harm to patients 81.3% the complaints and the nursing staff was the main notifier. CONCLUSION: The HGWA presents a program of effective risk management, maintaining and working on positive indicators for the safety of the patient. Even more important is to note that you can perform a quality service in terms of risk management, even when it comes to a public hospital in northeastern Brazil with financial constraints.
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spelling info:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/masterThesisStudy of adverse events in an accredited secondary hospital of CearÃ: an approach to risk managementEstudo dos eventos adversos em um hospital secundÃrio acreditado do CearÃ: uma abordagem no gerenciamento de riscos2011-08-29Marta Maria de FranÃa Fonteles28529839315http://lattes.cnpq.br/0574180390413250MÃnica Cardoso FaÃanha10472770349http://lattes.cnpq.br/6525793161073131Mirian Parente Monteiro1550764535300362508305http://lattes.cnpq.br/3243266961908364 Milena Pontes Portela BezerraUniversidade Federal do CearÃPrograma de PÃs-GraduaÃÃo em CiÃncias FarmacÃuticasUFCBRRisk Management Adverse Drug Reaction Reporting Systems Adverse Effects.FARMACIAStudy of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management. Author: Milena Pontes Portela Beserra. Supervisor: ProfÂ. Dr Marta Maria de FranÃa Fonteles. [Master degreeâs dissertation. Post Graduation in Pharmaceutical Science. Department of Pharmacy â Federal University of CearÃ]. BACKGROUND: Hospital Risk Management acts in the prevention, detection, control or eliminate risks that could cause harm to patients, in Brazil this concept was implemented in 2001 by the National Agency for Sanitary Surveillance (Anvisa), Ministry of Health with the project Sentinel Hospitals, and currently brings together nearly two hundred institutions. It consists basically of three pillars: pharmacovigilance, haemovigilance and technical surveillance. Indicators of results and adverse events are fundamental tools of quality by pointing out aspects of care that can be improved by making patient care without risks and failures, and therefore safer. In order to improve the quality of healthcare services in recent decades had the strength of the Hospital Accreditation Program consisting of external evaluation system that verifies the compliance of the structure and care processes with the adopted set of standards previously established. OBJECTIVES: To study adverse events suffered by hospitalized patients or that were related to drugs and related in a public secondary hospital accredited by National Accreditation Organization (ONA), in 2010, contextualizing the risk management approach in the hospital. METHODS: We conducted a retrospective documentary base at the Hospital General Dr. Waldemar Alcantara (HGWA) a survey of all reports of adverse drug reactions (ADRs), reactions to blood products and technical defects of materials, equipment and drugs, studying, and the risk management with a focus on pharmacovigilance, haemovigilance and technical surveillance, respectively. RESULTS AND DISCUSSION: There have been 271 events, with 166 (61.3%) RAM, 64 (23.6%) technical defects, 41 (15.1%) transfusion reactions. We found a higher number of RAM in patients with extreme age and use of antimicrobials, as well as previously reported. The main reported ADRs were dermatological and medical groups were more involved antimicrobials for systemic use. The main blood component was transfused red blood cells, is also a major cause of anemia, transfusion reactions and the main indication. The most transfusion reactions reported were fever (55.6%), dyspnea (8.9%) and urticaria (8.9%), these reactions were immediate in 92.7% of cases, they occurred in up to 24 hours after transfusion. Techniques have been reported 64 complaints of 40 different products, the main products cited were: saline 100 mL closed system (14.1%) and micropore tape (7.8%). Had the potential to cause direct harm to patients 81.3% the complaints and the nursing staff was the main notifier. CONCLUSION: The HGWA presents a program of effective risk management, maintaining and working on positive indicators for the safety of the patient. Even more important is to note that you can perform a quality service in terms of risk management, even when it comes to a public hospital in northeastern Brazil with financial constraints.Estudo dos eventos adversos em um hospital secundÃrio acreditado do CearÃ: uma abordagem no gerenciamento de riscos. Autora: Milena Pontes Portela Beserra. Orientadora: ProfÂ. DrÂ. Marta Maria de FranÃa Fonteles. [DissertaÃÃo de Mestrado â PÃs-graduaÃÃo em CiÃncias FarmacÃuticasâ Departamento de FarmÃcia da Universidade Federal do CearÃ]. INTRODUÃÃO: O Gerenciamento de Riscos Hospitalares atua na prevenÃÃo, detecÃÃo, controle ou eliminaÃÃo de riscos capazes de causar danos aos pacientes. No Brasil este conceito foi implantado em 2001 pela AgÃncia Nacional de VigilÃncia SanitÃria (Anvisa), do MinistÃrio da SaÃde, com o projeto Hospitais Sentinela, e, atualmente, congrega quase duas centenas de instituiÃÃes. à constituÃdo basicamente por trÃs pilares: farmacovigilÃncia, hemovigilÃncia e tecnovigilÃncia. Indicadores de resultados como os eventos adversos sÃo ferramentas fundamentais da qualidade por apontarem aspectos do cuidado que podem ser melhorados tornando a assistÃncia aos pacientes livre de riscos e falhas e, portanto, mais segura. Com o objetivo de melhorar a qualidade assistencial dos serviÃos, nas Ãltimas dÃcadas, tiveram forÃa os Programas de AcreditaÃÃo Hospitalar que consistem em sistema de avaliaÃÃo externa que verifica a concordÃncia da estrutura e dos processos assistenciais adotados com o conjunto de padrÃes previamente estabelecidos. OBJETIVOS: Estudar eventos adversos que acometeram os pacientes internados ou que se relacionaram a medicamentos e correlatos, em um hospital pÃblico secundÃrio acreditado pela OrganizaÃÃo Nacional de AcreditaÃÃo (ONA), no ano de 2010, contextualizando a abordagem no gerenciamento de risco hospitalar. MÃTODOS: Foi realizado um estudo retrospectivo de base documental no Hospital Geral Dr Waldemar AlcÃntara (HGWA) com levantamento de todas as notificaÃÃes de reaÃÃes adversas a medicamentos (RAM), reaÃÃes aos hemocomponentes e queixas tÃcnicas de materiais, equipamentos e medicamentos, estudando, assim, o gerenciamento de riscos com foco na farmacovigilÃncia, hemovigilÃncia e tecnovigilÃncia, respectivamente. RESULTADOS E DISCUSSÃO: Foram notificados 271 eventos, sendo 166 (61,3%) RAM, 64 (23,6%) queixas tÃcnicas e 41 (15,1%) reaÃÃes transfusionais. Foi encontrado maior nÃmero de RAM nos pacientes pertencentes aos extremos etÃrios e em uso de antimicrobianos, conforme jà bem descrito na literatura. As principais RAM notificadas foram as dermatolÃgicas e o grupo medicamentoso mais envolvido foram os antimicrobianos de uso sistÃmico. O principal hemocomponente transfundido foi o concentrado de hemÃcias, sendo tambÃm o maior causador de reaÃÃes transfusionais e a anemia a principal indicaÃÃo. As reaÃÃes transfusionais mais notificadas foram: febre (55,6%), dispnÃia (8,9%) e urticÃria (8,9%), essas reaÃÃes foram imediatas em 92,7% dos casos, pois ocorreram em atà 24h apÃs a transfusÃo. Foram notificadas 64 queixas tÃcnicas de 40 produtos diferentes, os principais produtos citados foram: o soro fisiolÃgico 100mL sistema fechado (14,1%) e fita microporosa (7,8%). PossuÃam potencial para causar dano direto aos pacientes 81,3% das queixas e a equipe de enfermagem foi a principal notificadora. CONCLUSÃO: O HGWA apresenta um programa de gerenciamento de riscos eficiente, com manutenÃÃo de indicadores positivos e trabalhando em prol da seguranÃa do paciente. Ainda mais importante à ressaltar que à possÃvel realizar um serviÃo de qualidade, em termos de gerenciamento de riscos, mesmo quando se trata de um hospital pÃblico do nordeste brasileiro com limitaÃÃes financeiras. CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superiorhttp://www.teses.ufc.br/tde_busca/arquivo.php?codArquivo=7401application/pdfinfo:eu-repo/semantics/openAccessporreponame:Biblioteca Digital de Teses e Dissertações da UFCinstname:Universidade Federal do Cearáinstacron:UFC2019-01-21T11:20:22Zmail@mail.com -
dc.title.en.fl_str_mv Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management
dc.title.alternative.pt.fl_str_mv Estudo dos eventos adversos em um hospital secundÃrio acreditado do CearÃ: uma abordagem no gerenciamento de riscos
title Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management
spellingShingle Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management
Milena Pontes Portela Bezerra
Risk Management
Adverse Drug Reaction Reporting Systems
Adverse Effects.
FARMACIA
title_short Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management
title_full Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management
title_fullStr Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management
title_full_unstemmed Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management
title_sort Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management
author Milena Pontes Portela Bezerra
author_facet Milena Pontes Portela Bezerra
author_role author
dc.contributor.advisor1.fl_str_mv Marta Maria de FranÃa Fonteles
dc.contributor.advisor1ID.fl_str_mv 28529839315
dc.contributor.advisor1Lattes.fl_str_mv http://lattes.cnpq.br/0574180390413250
dc.contributor.referee1.fl_str_mv MÃnica Cardoso FaÃanha
dc.contributor.referee1ID.fl_str_mv 10472770349
dc.contributor.referee1Lattes.fl_str_mv http://lattes.cnpq.br/6525793161073131
dc.contributor.referee2.fl_str_mv Mirian Parente Monteiro
dc.contributor.referee2ID.fl_str_mv 15507645353
dc.contributor.authorID.fl_str_mv 00362508305
dc.contributor.authorLattes.fl_str_mv http://lattes.cnpq.br/3243266961908364
dc.contributor.author.fl_str_mv Milena Pontes Portela Bezerra
contributor_str_mv Marta Maria de FranÃa Fonteles
MÃnica Cardoso FaÃanha
Mirian Parente Monteiro
dc.subject.eng.fl_str_mv Risk Management
Adverse Drug Reaction Reporting Systems
Adverse Effects.
topic Risk Management
Adverse Drug Reaction Reporting Systems
Adverse Effects.
FARMACIA
dc.subject.cnpq.fl_str_mv FARMACIA
dc.description.sponsorship.fl_txt_mv CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior
dc.description.abstract.por.fl_txt_mv Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management. Author: Milena Pontes Portela Beserra. Supervisor: ProfÂ. Dr Marta Maria de FranÃa Fonteles. [Master degreeâs dissertation. Post Graduation in Pharmaceutical Science. Department of Pharmacy â Federal University of CearÃ]. BACKGROUND: Hospital Risk Management acts in the prevention, detection, control or eliminate risks that could cause harm to patients, in Brazil this concept was implemented in 2001 by the National Agency for Sanitary Surveillance (Anvisa), Ministry of Health with the project Sentinel Hospitals, and currently brings together nearly two hundred institutions. It consists basically of three pillars: pharmacovigilance, haemovigilance and technical surveillance. Indicators of results and adverse events are fundamental tools of quality by pointing out aspects of care that can be improved by making patient care without risks and failures, and therefore safer. In order to improve the quality of healthcare services in recent decades had the strength of the Hospital Accreditation Program consisting of external evaluation system that verifies the compliance of the structure and care processes with the adopted set of standards previously established. OBJECTIVES: To study adverse events suffered by hospitalized patients or that were related to drugs and related in a public secondary hospital accredited by National Accreditation Organization (ONA), in 2010, contextualizing the risk management approach in the hospital. METHODS: We conducted a retrospective documentary base at the Hospital General Dr. Waldemar Alcantara (HGWA) a survey of all reports of adverse drug reactions (ADRs), reactions to blood products and technical defects of materials, equipment and drugs, studying, and the risk management with a focus on pharmacovigilance, haemovigilance and technical surveillance, respectively. RESULTS AND DISCUSSION: There have been 271 events, with 166 (61.3%) RAM, 64 (23.6%) technical defects, 41 (15.1%) transfusion reactions. We found a higher number of RAM in patients with extreme age and use of antimicrobials, as well as previously reported. The main reported ADRs were dermatological and medical groups were more involved antimicrobials for systemic use. The main blood component was transfused red blood cells, is also a major cause of anemia, transfusion reactions and the main indication. The most transfusion reactions reported were fever (55.6%), dyspnea (8.9%) and urticaria (8.9%), these reactions were immediate in 92.7% of cases, they occurred in up to 24 hours after transfusion. Techniques have been reported 64 complaints of 40 different products, the main products cited were: saline 100 mL closed system (14.1%) and micropore tape (7.8%). Had the potential to cause direct harm to patients 81.3% the complaints and the nursing staff was the main notifier. CONCLUSION: The HGWA presents a program of effective risk management, maintaining and working on positive indicators for the safety of the patient. Even more important is to note that you can perform a quality service in terms of risk management, even when it comes to a public hospital in northeastern Brazil with financial constraints.
Estudo dos eventos adversos em um hospital secundÃrio acreditado do CearÃ: uma abordagem no gerenciamento de riscos. Autora: Milena Pontes Portela Beserra. Orientadora: ProfÂ. DrÂ. Marta Maria de FranÃa Fonteles. [DissertaÃÃo de Mestrado â PÃs-graduaÃÃo em CiÃncias FarmacÃuticasâ Departamento de FarmÃcia da Universidade Federal do CearÃ]. INTRODUÃÃO: O Gerenciamento de Riscos Hospitalares atua na prevenÃÃo, detecÃÃo, controle ou eliminaÃÃo de riscos capazes de causar danos aos pacientes. No Brasil este conceito foi implantado em 2001 pela AgÃncia Nacional de VigilÃncia SanitÃria (Anvisa), do MinistÃrio da SaÃde, com o projeto Hospitais Sentinela, e, atualmente, congrega quase duas centenas de instituiÃÃes. à constituÃdo basicamente por trÃs pilares: farmacovigilÃncia, hemovigilÃncia e tecnovigilÃncia. Indicadores de resultados como os eventos adversos sÃo ferramentas fundamentais da qualidade por apontarem aspectos do cuidado que podem ser melhorados tornando a assistÃncia aos pacientes livre de riscos e falhas e, portanto, mais segura. Com o objetivo de melhorar a qualidade assistencial dos serviÃos, nas Ãltimas dÃcadas, tiveram forÃa os Programas de AcreditaÃÃo Hospitalar que consistem em sistema de avaliaÃÃo externa que verifica a concordÃncia da estrutura e dos processos assistenciais adotados com o conjunto de padrÃes previamente estabelecidos. OBJETIVOS: Estudar eventos adversos que acometeram os pacientes internados ou que se relacionaram a medicamentos e correlatos, em um hospital pÃblico secundÃrio acreditado pela OrganizaÃÃo Nacional de AcreditaÃÃo (ONA), no ano de 2010, contextualizando a abordagem no gerenciamento de risco hospitalar. MÃTODOS: Foi realizado um estudo retrospectivo de base documental no Hospital Geral Dr Waldemar AlcÃntara (HGWA) com levantamento de todas as notificaÃÃes de reaÃÃes adversas a medicamentos (RAM), reaÃÃes aos hemocomponentes e queixas tÃcnicas de materiais, equipamentos e medicamentos, estudando, assim, o gerenciamento de riscos com foco na farmacovigilÃncia, hemovigilÃncia e tecnovigilÃncia, respectivamente. RESULTADOS E DISCUSSÃO: Foram notificados 271 eventos, sendo 166 (61,3%) RAM, 64 (23,6%) queixas tÃcnicas e 41 (15,1%) reaÃÃes transfusionais. Foi encontrado maior nÃmero de RAM nos pacientes pertencentes aos extremos etÃrios e em uso de antimicrobianos, conforme jà bem descrito na literatura. As principais RAM notificadas foram as dermatolÃgicas e o grupo medicamentoso mais envolvido foram os antimicrobianos de uso sistÃmico. O principal hemocomponente transfundido foi o concentrado de hemÃcias, sendo tambÃm o maior causador de reaÃÃes transfusionais e a anemia a principal indicaÃÃo. As reaÃÃes transfusionais mais notificadas foram: febre (55,6%), dispnÃia (8,9%) e urticÃria (8,9%), essas reaÃÃes foram imediatas em 92,7% dos casos, pois ocorreram em atà 24h apÃs a transfusÃo. Foram notificadas 64 queixas tÃcnicas de 40 produtos diferentes, os principais produtos citados foram: o soro fisiolÃgico 100mL sistema fechado (14,1%) e fita microporosa (7,8%). PossuÃam potencial para causar dano direto aos pacientes 81,3% das queixas e a equipe de enfermagem foi a principal notificadora. CONCLUSÃO: O HGWA apresenta um programa de gerenciamento de riscos eficiente, com manutenÃÃo de indicadores positivos e trabalhando em prol da seguranÃa do paciente. Ainda mais importante à ressaltar que à possÃvel realizar um serviÃo de qualidade, em termos de gerenciamento de riscos, mesmo quando se trata de um hospital pÃblico do nordeste brasileiro com limitaÃÃes financeiras.
description Study of adverse events in an accredited secondary hospital of CearÃ: an approach to risk management. Author: Milena Pontes Portela Beserra. Supervisor: ProfÂ. Dr Marta Maria de FranÃa Fonteles. [Master degreeâs dissertation. Post Graduation in Pharmaceutical Science. Department of Pharmacy â Federal University of CearÃ]. BACKGROUND: Hospital Risk Management acts in the prevention, detection, control or eliminate risks that could cause harm to patients, in Brazil this concept was implemented in 2001 by the National Agency for Sanitary Surveillance (Anvisa), Ministry of Health with the project Sentinel Hospitals, and currently brings together nearly two hundred institutions. It consists basically of three pillars: pharmacovigilance, haemovigilance and technical surveillance. Indicators of results and adverse events are fundamental tools of quality by pointing out aspects of care that can be improved by making patient care without risks and failures, and therefore safer. In order to improve the quality of healthcare services in recent decades had the strength of the Hospital Accreditation Program consisting of external evaluation system that verifies the compliance of the structure and care processes with the adopted set of standards previously established. OBJECTIVES: To study adverse events suffered by hospitalized patients or that were related to drugs and related in a public secondary hospital accredited by National Accreditation Organization (ONA), in 2010, contextualizing the risk management approach in the hospital. METHODS: We conducted a retrospective documentary base at the Hospital General Dr. Waldemar Alcantara (HGWA) a survey of all reports of adverse drug reactions (ADRs), reactions to blood products and technical defects of materials, equipment and drugs, studying, and the risk management with a focus on pharmacovigilance, haemovigilance and technical surveillance, respectively. RESULTS AND DISCUSSION: There have been 271 events, with 166 (61.3%) RAM, 64 (23.6%) technical defects, 41 (15.1%) transfusion reactions. We found a higher number of RAM in patients with extreme age and use of antimicrobials, as well as previously reported. The main reported ADRs were dermatological and medical groups were more involved antimicrobials for systemic use. The main blood component was transfused red blood cells, is also a major cause of anemia, transfusion reactions and the main indication. The most transfusion reactions reported were fever (55.6%), dyspnea (8.9%) and urticaria (8.9%), these reactions were immediate in 92.7% of cases, they occurred in up to 24 hours after transfusion. Techniques have been reported 64 complaints of 40 different products, the main products cited were: saline 100 mL closed system (14.1%) and micropore tape (7.8%). Had the potential to cause direct harm to patients 81.3% the complaints and the nursing staff was the main notifier. CONCLUSION: The HGWA presents a program of effective risk management, maintaining and working on positive indicators for the safety of the patient. Even more important is to note that you can perform a quality service in terms of risk management, even when it comes to a public hospital in northeastern Brazil with financial constraints.
publishDate 2011
dc.date.issued.fl_str_mv 2011-08-29
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