Hazard Communication, also known as HazCom, was established by the Occupational Safety and Health Administration (OSHA) to ensure employers and employees understand the hazards associated with the chemicals they work with. HazCom aims to reduce the risk of injury or illness caused by exposure to dangerous chemicals in the workplace.

What is the Hazard Communication Standard?

The Hazard Communication Standard (HCS) requires employers to provide information about the hazards of chemicals in the workplace, including information about the proper handling, storage, and disposal of these chemicals. This information must be communicated to employees through labels, safety data sheets (SDSs), and training programs.

What is Hazard Communication training?

Hazard Communication training is designed to educate employees on the potential hazards of chemicals and other dangerous materials in the workplace. This training is required by OSHA and is intended to ensure that employees are aware of the risks associated with the materials they work with and the proper procedures for handling and storing them. The training typically covers labelling requirements, safety data sheets, and emergency response procedures.

How often must Hazard Communication training take place?

Hazard Communication training must be provided when an employee is first hired, whenever a new hazardous chemical is introduced into the workplace, and whenever there is a change in the hazards associated with a chemical.

In addition to these requirements, employers must maintain a site-specific written Hazard Communication program outlining their procedures for complying with the HCS (29 CFR 1910.1200).

Experience Better Healthcare Compliance

Stay compliant with OSHA, HIPAA, and billing regulations. See how our comprehensive solutions can simplify your compliance needs and enhance your practice’s efficiency.

The post What Organization’s Need to Know About Hazard Communication appeared first on MedSafe.

Becker’s Hospital Review reported that 9 in 10 healthcare workers have witnessed or experienced violence in the workplace and a Press Ganey report suggested that more than two nurses were assaulted every hour in Q2 2022.

The numbers are alarming, and the consequences to the healthcare system are severe. Not only does violence in the healthcare workplace cause physical and psychological harm, but when clinicians and medical personnel are afraid for their safety, it makes it more difficult to provide quality patient care. In addition, violence at healthcare facilities takes up valuable resources that can delay urgent care for other patients. It also lowers patient satisfaction and employee productivity and increases the potential for adverse medical events.

When Does Healthcare Violence Occur?

Research has shown that healthcare industry violence often occurs during times of high activity and interaction with patients. For example, assaults may occur when service is denied, when a patient is admitted against their will, or when a healthcare worker attempts to set limits on eating, drinking, or smoking. As we’ve seen in recent months, violence can also be random in nature.

Although anyone working in a hospital or healthcare facility can become a victim of violence, doctors, nurses and all other staff involved in patient care are at the highest risk. Safety for healthcare workers is critical, and feeling safe in the workplace is a crucial element in creating a comfortable and healing environment for all.

Although there is not one single solution, there are ways to minimize risk. Workplace safety training can help increase worker and employer awareness of the risk factors for violence in healthcare facilities and provide strategies for reducing exposure, including how to defuse potentially dangerous situations and keeping themselves and others safe. All employers should have a Workplace Violence Prevention Safety Training Program in place to help prevent potential violent injuries in healthcare facilities.

Experience Better Healthcare Compliance

MedSafe is the nation’s leading one-stop resource for outsourced accreditation and healthcare compliance solutions. For over 20 years, we have been providing peace of mind to hospital groups, private practices, and their business associates. Our suite of onsite and online training services, including OSHA, HIPAA, Corporate Compliance and Code Auditing better equip your practice with the necessary tools and skills to achieve and maintain regulatory billing compliance. MedSafe takes a hands-on approach and works directly with your team to uncover issues and define suitable solutions.

The post What You Should Know About Increasing Violence in the Healthcare Workplace appeared first on MedSafe.

1) What is OSHA?

OSHA has two meanings: 

1. The Occupational Safety and Health Act (OSHA)- was signed into law in 1970. It was designed to assure safe and healthful working conditions for workers by setting and enforcing standards and providing training, outreach, education, and assistance.
2. The Occupational Safety and Health Administration (OSHA) – is the government agency responsible for enforcing compliance with the Act.

2) Why is OSHA important?

The OSHA Act protects the safety and health of workers. It requires employers to provide a working environment free from recognized hazards which includes taking measures to mitigate the risk of illness, injury, or death. 

3) What does OSHA do?

OSHA develops and enforces standards and a variety of regulations. The agency also offers training, outreach, and assistance to ensure safe and healthy working conditions.

4) What is OSHA compliance?

OSHA compliance is following the safety and health standards that apply to a business in order to ensure a safe and healthy workplace and workforce. OSHA requires facilities to provide annual training to staff, have written policies and procedures for employees to access as needed, and requires facilities to have their documentation in order.

5) What are some of the most common OSHA violations?

A list of the top 10 OSHA violations for the healthcare industry includes:

1. Respiratory Protection (1910.134)
2. Bloodborne Pathogens (1910.130)
3. Reporting Fatalities/Injuries (1904.39)
4. Hazard Communication (1910.1200)
5. OSHA Recordkeeping (1904.4)
6. General PPE (1910.132)
7. OSHA Recordkeeping Forms (1904.29)
8. General Electrical Requirements (1910.303)
9. Fire Extinguishers (1910.157)
10. OSHA Recordkeeping/Providing Records (1904.40)

6) How does OSHA enforce its standards?

Employers are required to submit reports of any fatalities and injuries or illnesses resulting in hospitalization. At the same time, workers can file a complaint and ask OSHA to inspect the workplace if there is a serious hazard or if an employer is non-compliant.

7) What are OSHA penalties for non-compliance?

OSHA penalties can vary from $0-$70,000, depending on how serious the violation. While OSHA training can be time-consuming, it is one of the best defenses to protect businesses from liability. Training is also crucial to ensuring safe working conditions. 

8) What is OSHA training?

OSHA training is safety and health training that employers are required to provide to their workforce. Training requirements can vary based on the industry. OSHA requires all employees to be trained annually. What is most important is the content of the training and ensuring the information is being taught effectively. OSHA also requires training to be documented with the following:

• Dates of training 
• Information covered in the training 
• Names and qualifications of trainers
• Names and titles of attendees

Experience Better Healthcare Compliance

MedSafe is the nation’s leading one-stop resource for outsourced accreditation and healthcare compliance solutions. For over 20 years, we have been providing peace of mind to hospital groups, private practices, and their business associates. Our suite of onsite and online training services, including OSHA, HIPAA, Corporate Compliance and Code Auditing better equip your practice with the necessary tools and skills to achieve and maintain regulatory billing compliance. MedSafe takes a hands-on approach and works directly with your team to uncover issues and define suitable solutions.

The post 8 Most Common OSHA FAQs appeared first on MedSafe.

Slips, trips and falls are among the leading causes of workplace injuries and death. In 2020, 805 workers died in falls, and 211,640 were injured badly enough to require days off of work. Fall injuries frequently result in disabling injuries that impact an employee’s ability to do their job, often resulting in lost workdays and reduced productivity. Work-related fall injuries also create a considerable financial burden from medical costs to worker’s compensation; the costs are estimated to be $70 billion annually in the United States.

Workplace Fall Prevention Tips

The good news is that most falls are preventable. There are many proactive steps employers can take to lower the risk of injury in the workplace.

1. Keep walkways clear – keep walking areas clean and clear of clutter. An unobstructed path reduces the risk of an employee slipping or tripping on an unexpected object. 
2. Clean up spills – encourage all employees to clean up any spills immediately. If a spill occurs, place warning signs around the hazard and clean it up right away to avoid an accident.
3. Make sure stairs and handrails are safe– stairs are a common area for workplace injuries to occur. Be sure to keep stairwells clear and well-lit. Make sure stairways have handrails, and the top and bottom stairs are clearly marked with reflective tape.
4. Encourage appropriate footwear- ensure employees wear the appropriate footwear for their working conditions. Non-slip shoes with traction help reduce the risk of slip and fall injuries.
5. Install proper lighting- Employers can help reduce the risk of employee slips, trips or falls by installing proper lighting both outside and inside the workplace.
6. Check and repair all flooring- check all flooring inside and outside the building to ensure there are no potential hazards such as cracks or holes. Be sure to fix any problem areas and place warning signs around areas that need repair.
7. Use signs- For areas that may be a potential hazard, use clear signage to bring attention to the problem area and reduce the risk of an accident.
8. Safety training- employee training is essential for reducing the risk of injury in the workplace. Ensure all employees have been trained adequately on safety guidelines.

Experience Better Healthcare Compliance

MedSafe is the nation’s leading one-stop resource for outsourced accreditation and healthcare compliance solutions. For over 20 years, we have been providing peace of mind to hospital groups, private practices, and their business associates. Our suite of onsite and online training services, including OSHA, HIPAA, Corporate Compliance and Code Auditing better equip your practice with the necessary tools and skills to achieve and maintain regulatory billing compliance. MedSafe takes a hands-on approach and works directly with your team to uncover issues and define suitable solutions.

The post National Safety Month Fall Prevention Tips appeared first on MedSafe.

As per the Occupational Safety and health Administration, “Many employers with more than 10 employees are required to keep a record of serious work-related injuries and illnesses. (Certain low-risk industries are exempted.) 

Although dental and physician offices are exempt, keep in mind that dental and physician offices are not exempt from recording injuries on a sharps injury log or from documenting incidents of exposures to bloodborne pathogens.  Additionally, other injuries, including first aid, should be documented. 

How does OSHA record keeping requirements define a recordable injury or illness?

• Any work-related fatality.
• Any work-related injury or illness that results in loss of consciousness, days away from work,   restricted work, or transfer to another job.
• Any work-related injury or illness requiring medical treatment beyond first aid.
• Any work-related diagnosed case of cancer, chronic irreversible diseases, fractured or cracked bones or teeth, and punctured eardrums.

There are also special recording criteria for work-related cases involving: needlesticks and sharps injuries; medical removal; hearing loss; and tuberculosis.

How does OSHA define first aid?

• Using a non-prescription medication at nonprescription strength (for medications available in both prescription and non-prescription form, a recommendation by a physician or other licensed health care professional to use a non-prescription medication at prescription strength is considered medical treatment for recordkeeping purposes);
• Administering tetanus immunizations (other immunizations, such as Hepatitis B vaccine or rabies vaccine, are considered medical treatment); Cleaning, flushing or soaking wounds on the surface of the skin
• Using wound coverings such as bandages, Band-Aids, gauze pads, etc.; or using butterfly bandages or Steri-Strips (other wound closing devices such as sutures, staples, etc., are considered medical treatment);
• Using hot or cold therapy;
• Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc. (devices with rigid stays or other systems designed to immobilize parts of the body are considered medical treatment for recordkeeping purposes);
• Using temporary immobilization devices while transporting an accident victim (e.g., splints, slings, neck collars, back boards, etc.). Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister;
• Using eye patches;
• Removing foreign bodies from the eye using only irrigation or a cotton swab;
• Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs or other simple means;
• Using finger guards;
• Using massages (physical therapy or chiropractic treatment are considered medical treatment for recordkeeping purposes); or
• Drinking fluids for relief of heat stress.

This information helps employers, workers and OSHA evaluate the safety of a workplace, understand industry hazards, and implement worker protections to reduce and eliminate hazards -preventing future workplace injuries and illnesses.”

All employers that are required to maintain an OSHA 300 Injury and Illness log must post the accompanying OSHA 300A summary sheet in their workplace.  The OSHA Form 300A ‘Summary of Work-Related Injuries and Illnesses’ for the 2022 calendar year must be posted beginning Tuesday, February 1.  The summary log must be posted at each facility in a common area where all employees are accustomed to viewing notices until Saturday, April 30.

Prior to posting the 300A form, an employer or company executive must review the related OSHA 300 log and certify that the documented information is correct and complete by signing/dating the OSHA 300A summary form.  Companies with no recordable injuries or illnesses must post the summary form showing zeros on the total line.  If you have any questions about what injuries and illnesses must be documented, read OSHA Guidelines for Recordkeeping (29 CFR 1904).

If your organization is concerned about OSHA record keeping and reporting requirements, contact the experts at MedSafe.

MedSafe is the leading one-stop resource in providing safety and compliance training programs in the United States. We offer onsite training and a wide variety of online training courses.

Contact us today for a free consultation!

Toll-free: (888) MED-SAFE

www.medsafe.com

References:

https://www.osha.gov/recordkeeping/

The post OSHA Injury and Illness Record Keeping and Reporting Requirements appeared first on MedSafe.

This rule applies to all settings where healthcare services or healthcare support services are provided and where suspected or confirmed COVID-19 patients are treated.  This includes employees in hospitals, emergency responders, nursing homes and assisted living facilities, home healthcare workers, and in ambulatory care facilities.  However, there are certain enumerated exceptions. 

The ETS doesn’t apply to these healthcare settings:

• First aid performed by an employee who is not a licensed healthcare provider.
• Pharmacists in a retail setting.
• Non-hospital ambulatory care settings where non-employees are screened for suspected or confirmed COVID-19.
• Hospital ambulatory care settings where employees are fully vaccinated and non-employees are screened prior to entry.
• Home healthcare settings where employees are fully vaccinated and non-employees are screened prior to entry.
• Healthcare support services not performed in a healthcare setting, i.e., offsite laundry offsite medical billing.
• Telehealth services performed outside of a setting where direct patient care occurs.

According to OSHA, “For healthcare settings embedded in nonhealthcare settings, the ETS applies only to the embedded healthcare setting and not to the remainder of the physical location. Where emergency responders or other licensed healthcare providers enter a non-healthcare setting to provide healthcare services, the ETS applies only to the provision of healthcare services by that employee. The ETS exempts fully vaccinated workers from masking, distancing, and barrier requirements when in well-defined areas where there is no reasonable expectation that any person with suspected or confirmed COVID-19 will be present.”

If your setting is covered under the ETS, the following is a brief listing of the key requirements. 

Note: Consult the standard for full details.

• Develop a COVID-19 Plan.
• Patient Screening and management, limiting access to where direct patient care is provided.
• Standard and Transmission-Based Precautions, following CDC guidelines.
• Personal protective Equipment (PPE), ensuring appropriate use by employees.
• Limiting the exposure to aerosol-generating procedures on a person with suspected or Confirmed COVID-19.
• Physical distancing and install physical barriers at fixed work locations in non-patient care areas.
• Cleaning and disinfection, following the CDC guidelines.
• Monitor ventilation systems.
• Conducting regular health screening of employees, report any positive cases of COVID-19.
• Vaccination, reasonable time and paid leave for vaccination and vaccine side effects.
• Training.
• Prohibition on retaliation.
• Requirements must be implemented at no cost to employees.
• Recordkeeping, COVID-19 log (only required if more than 10 employees).
• Reporting COVID-19 fatalities and hospitalizations to OSHA.
• Mini respiratory protection program (29 CFR 1910.504), only under certain circumstances.

MedSafe will provide additional updates as appropriate.

For further information or assistance on these requirements, please contact your MedSafe Team.

Toll-free: (888) MED-SAFE

www.medsafe.com

The post OSHA’s Emergency Temporary Standard (ETS) Update appeared first on MedSafe.

Most medical practices in the US have re-opened, and the majority are adhering to strict safety procedures provided by the Centers for Disease Control (CDC). Among these guidelines are social-distancing measures for physician practices, which take very careful planning and coordination. In addition, to measures such as wearing masks, frequent hand washing, and disinfecting below are a few tips for practicing social distancing in the medical practice:

1. Optimize the use of telehealth whenever possible.
2. Consider allowing most administrative and back-office employees to work remotely.
3. Reduce the number of employees allowed in common areas such as breakrooms.
4. If there are work areas, ensure computers are arranged at least 6 feet apart.
5. Try to transition educational or administrative meetings to virtual.
6. Consider closing the waiting room and asking patients to wait in their cars or outside the practice until they receive a text or call to enter the office. Implementing a digital check-in solution will help practices reduce the handling of paperwork.
7. Limit visitors to only those essential for a patient’s physical or emotional well-being and care. If possible, consider using separate entrances for sick and well patients.
8. Assess all visitors for fever and other COVID-19 symptoms before entry to the facility.
9. Limit potential exposure by keeping exam room doors closed. Ideally, designate an exam room in the back of the office for suspected patients, far away from other staff and patients.
10. Training- assess the need for training and review of COVID-19 screening and triage protocols, patient management, use of PPE, patient communications, and policies and procedures. Make sure to document all training provided and maintain records in administrative files.

For More Information on Medical Practice Social Distancing Contact MedSafe

If your practice is seeking safety or COVID-19 social distance training, contact the experts at MedSafe. MedSafe is the nation’s leading one-stop resource for outsourced safety, training, and health compliance solutions. We offer a wide variety of onsite and online training courses, including OSHA Safety, Corporate Compliance, HIPAA, Billing Compliance, and Harassment and Discrimination in the Workplace.

MedSafe is offering a free course on social distancing coming soon!

Contact us today for a free training consultation.

Toll-free: (888) MED-SAFE

www.medsafe.com

The post Best Practices for Medical Practice Social Distancing appeared first on MedSafe.

This guide answers essential questions regarding the implementation of these safety protocols, providing actionable advice and detailed steps to maintain a safe and effective healthcare environment amid ongoing challenges.

1)     How can a medical practice establish effective medical staff safety protocols?

The CDC recommends the following best practices:

·       Implement source control for all visitors, patients, and staff entering your practice or health care facility, regardless of symptoms.

·       Encourage patients and visitors to wear cloth masks when visiting to prevent transmission from non-symptomatic individuals.

·       Screen patients and visitors for symptoms of acute respiratory illness (e.g., fever, cough, difficulty breathing) before entering your health care facility.

·       Ensure proper use of personal protective equipment (PPE).

·       Conduct an inventory of available PPE.

·       Encourage sick employees to stay home.

Helpful links:

AAFP

2)   What steps can healthcare professionals take to stay healthy during the COVID-19 pandemic?

The CDC recommends specific safety measures that health care professionals can take to minimize exposure to PUI and confirmed COVID-19 cases and prevent the spread of infection within health care facilities.

Those steps include:

·       Implement source control for everyone entering a health care facility (e.g., health care personnel, patients, visitors), regardless of symptoms.

·       Set guidelines to help triage patients with symptoms congruent with COVID-19.

·       Utilize sanitation and hygiene stations.

·       Demonstrate proper use of PPE, including eye protection.

·       Assist in monitoring and restricting access for visitors and other nonessential personnel.

Helpful link:

AAFP

3)   Are N95 masks the standard of care?

Dental:  The highest-rated masks generally recommended for use in dental settings are N95 respirators, which are evaluated, tested, and approved by the National Institute for Occupational Safety and Health (NIOSH), a part of the CDC. N95 respirators filter at least 95% of airborne particles. They should be used when treating patients with or suspected of having respiratory illnesses. However, most dental practices should not need N95 respirators except perhaps for emergency treatments – with proper triaging, the treatment of patients presenting with symptoms of respiratory illnesses should be postponed until a later time when they have fully recovered. Interim guidelines state that the highest level of PPE should be available when treating patients.

Medical:  Medical staff working in a medical office need to wear a mask when seeing patients for appointments. A surgical face mask is appropriate to wear. The highest level of PPE should be available when treating patients.

Helpful links:

FDA

4)     How should PPE be disposed of after examining a patient?

If the disposable PPE is not visibly soiled with bodily fluids or splatter, then disposable PPE can be discarded in the regular trash. If the PPE is visibly soiled and/or has splatter on it, it needs to be disposed of in the appropriately marked Biohazard container.

5)     Can the HCP that have had exposure to COVID-19 patients go to work normally?

Asymptomatic HCP with a recognized COVID-19 exposure might be permitted to work in a crisis capacity strategy to address staffing shortages if they wear a facemask for source control for 14 days after the exposure. This time period is based on the current incubation period for COVID-19, which is 14 days.

6)     Can I use hand sanitizer in between patients if my hands are not soiled during this COVID pandemic?

Yes, unless soap and water are not available. Wash your hands after each patient for no less than 20 seconds.

7)     How do I know I have disinfected an exam room properly during the COVID pandemic?

Using an EPA-registered disinfectant product is best. Always be aware of the kill time for the product in use. This will insure proper disinfection. This should be documented in your infection control protocol.

To get answers to your COVID-19 questions, contact MedSafe

MedSafe is the nation’s leading one-stop resource for outsourced safety, training, and health compliance solutions. We offer a wide variety of onsite and online training courses, including OSHA Safety, Corporate Compliance, HIPAA, Billing Compliance, and Harassment and Discrimination in the Workplace.

Contact us today for a free training consultation.

Toll-free: (888) MED-SAFE

MedSafe

The post Top 7 COVID-19 Questions and Answers for Medical Practices appeared first on MedSafe.

Safety Tips for Practices:

1. Provide refresher safety training for medical staff on triage, infection control, use of personal protective equipment (PPE), and patient communication.
2. Follow safety guidelines from the Centers for Disease Control and Prevention (CDC) for COVID-19 screening patients.
3. Schedule in-person visits according to medical priority. Consider continued telehealth visits for patients at high risk for COVID-19 who don’t need to be seen in person.
4. Practices should require all individuals who visit the office to wear a cloth face covering. This expectation should be clearly explained to patients and other visitors before they arrive at the practice.
5. Avoid patient-to-patient contact by closing waiting rooms. Consider a separate entrance and exit door. Ask patients to wait in the car, and they will receive a text when a patient room is available. Allow only one-patient visits. If a patient must be accompanied, screen for COVID-19.
6. Heavy emphasis should be placed on deep cleaning all physician office waiting rooms, patient rooms, frequently touched surfaces including reception countertops, check-in equipment and areas, chairs, elevator buttons, doorknobs, railings, and restrooms. Consider removing all reading materials from the waiting room.
7. Consider the implementation of telehealth services. Patients with COVID-19 could be evaluated remotely and if found seriously ill, could be referred to the emergency department with prior notification of their arrival.
8. Post the practice’s policy for non-employees or patients outside the practice door and on your website. (including vendors, educators, service providers, etc.) Consider rerouting these visitors to phone or video conferences. For visitors who must enter the practice, designate a specific time to minimize potential interactions with patients and staff.
9. Determine the needs of staff for PPE based on levels of the types of patients they are seeing, the types of care and procedures performed, and infection in the community. Use the guidance from the Occupational Safety and Health Administration (OSHA). Also see the CDC guidelines
10. Contact your medical malpractice insurance carrier to ensure that you are protected from medical malpractice litigation. It is a good idea to discuss your current coverage and whether any additional coverage may be warranted.

The post COVID-19 Safety Tips for Medical Practices appeared first on MedSafe.

Before Patients Arrive

• Prepare the clinic.
• Know which of your patients are at higher risk of adverse outcomes from COVID-19.
• Consider and plan for providing more telemedicine appointments.
• Know how to contact your health department.
• Stay connected with your health department to know about COVID-19 in your community.
• Step up precautions when the virus is spreading in your community.
• Assess and restock supplies now and on a regular schedule.

Communicate with patients.

• Ask patients about symptoms during reminder calls.
• Consider rescheduling non-urgent appointments.
• Post signs at entrances and in waiting areas about prevention actions.
• Prepare the waiting area and patient rooms.
• Provide supplies—tissues, alcohol-based hand rub, soap at sinks, and trash cans.
• Place chairs 3–6 feet apart, when possible. Use barriers (like screens), if possible.
• If your office has toys, reading materials, or other communal objects, remove them or clean them regularly.

Train and prepare your staff now.

• Ensure that clinical staff know the right ways to put on, use, and take off PPE safely.
• Recognize the symptoms—fever, cough, shortness of breath.
• Implement procedures to quickly triage and separate sick patients.
• Emphasize hand hygiene and cough etiquette for everyone.
• Ask staff to stay home if they are sick.
• Send workers home if symptoms develop at work.

When Patients Arrive

• Place staff at the entrance to ask patients about their symptoms.
• Provide symptomatic patients with tissues or facemasks to cover mouth and nose.
• Limit non-patient visitors.
• Separate sick patients with symptoms.
• Allow patients to wait outside or in the car if they are medically able.
• Create separate spaces in waiting areas for sick and well patients.
• Place sick patients in a private room as quickly as possible.

After Patients are Assessed

• Provide at-home care instructions to patients with respiratory symptoms. Consider telehealth options for follow up.
• Notify your health department of patients with COVID-19 symptoms.
• After patients leave, clean frequently touched surfaces using EPA-registered disinfectants—counters, beds, seating.

For more information on COVID-19 visit:

https://www.cdc.gov/coronavirus/2019-ncov/

For More Information, Contact MedSafe

MedSafe currently has a COVID-19 Online Training Module available.

Please give us a call at 1-888-MED-SAFE if you’d like to add the training to your account.

www.medsafe.com

The post Best Practices for Medical Offices and Clinics During COVID-19 appeared first on MedSafe.