Lesson L3-1 · authored fragments (docs/43)
Primary review content — the AI-avatar narration, in order.
Before you touch a single medication, we start with your hands. Washing them is Step 1 of every med pass -- every resident, every time. APD is clear on this one: you wash before and after each resident you help, and again whenever you move from one route to another. Clean hands are what stop germs from moving from one resident, or one route, to the next. Most of the time, that means soap and water. Really scrub the spots germs like to hide -- your wrists, in between your fingers, and under your nails -- then dry your hands off. When your hands aren't dirty, you've got another option: you can use hand sanitizer instead of the sink. Just make sure it's an alcohol one, at least 60%. But here's the rule I never want you to forget. When your hands are soiled -- or might be -- sanitizer is not enough. Say you just helped a resident in the bathroom: your hands might look fine, but that's exactly when you go to the sink and wash with soap and water. On a busy morning it can feel like a detour. Do it anyway -- clean hands are how you protect the resident you're about to give medicine to.
15 of 15 critical claims are verified_by: null (Gate-2 SME sign-off pending → preview only, production-blocked under the Rule-3.6 waiver). · runtime budget: 4:30
# Concept mirror — MA.L3-1.A (Hand Hygiene — Step 1 of every pass)
> **MIRROR / NOTES ONLY.** The authoritative concept entry is **docs/42 §E, `MA.L3-1.A`**
> (Instructional Domain Model). This file is the local traceability ledger + decision queue for the
> derived-asset bundle; if it ever disagrees with docs/42, **docs/42 wins** (docs/43 §22 authority flow).
| Field | Value |
|---|---|
| `concept_id` | `MA.L3-1.A` |
| `competency_id` | `C-3.1` (Safe administration procedure) |
| `lesson_ids` | `[L3-1]` + **every route lesson** (topical, inhalation, ophthalmic, otic, rectal, enteral, transdermal) — *cross-cutting universal*, APD Mod2 s51 |
| `clinical_risk` | **Moderate→High** → ≥80% KC mastery; **not** 100%-gating; KC key **not** SME-protected |
| `medication_error_prevented` | Cross-contamination / pathogen transfer between clients and between routes |
| `sme_status` | `in_review` |
| `apd_traceability_status` | sourced — one open anchor (`TODO(source-L31A-1)`), one `[Waiver360-added]` technique anchor (`TODO(source-L31A-2)`), and the CDC **"20 seconds"** duration `[Needs Owner Review]` |
## Rule-3.6 author-ahead waiver (recorded 2026-07-05)
The concept is `in_review`, not `approved`. Per docs/42 §I.1 / docs/43 §4, this bundle is authored
**ahead of concept approval under a Rule-3.6 waiver** as part of the Oral Route (L3-1) reference
implementation. Consequence: **every fragment in this bundle is `sme_status: "draft"`, preview-flag
only, and production-publish-blocked** until (a) the concept reaches `approved` and (b) a Gate-2 SME
sign-off is recorded in `content_revisions.sme_signoff_*`.
## Source ledger (projects into `payload_json.sources`)
- `curriculum_source`: "APD BMA Module 2 s44, s51–52 (hand washing critical before/after each contact and between routes; sanitizer ≥60% if not visibly soiled). Checkpoints: Mod2 v2 Q29 / v4 Q13."
- `form_reference`: "— (no MAR form dependency; this concept precedes the MAR)"
| # | Claim | Tag | Source | verified_by |
|---|---|---|---|---|
| C1 | Hand washing is critical — before and after each client contact, and between different routes | `[APD]` | Mod2 s44, s51–52; checkpoints Mod2 v2 Q29 / v4 Q13 | null |
| C2 | If hands are **not visibly soiled**, an alcohol sanitizer of **≥60%** may be used instead of soap and water | `[APD]` | Mod2 s51–52 (concept field 7) | null |
| C3 | When hands are (or may be) soiled — e.g., right after assisting a client with toileting — **soap and water is required; sanitizer is not sufficient** | `[APD]`-derived + `[Waiver360-added]` example | Inverse of C2 (Mod2 s51–52) + concept KC #13; the *bathroom* specificity is instructional scaffolding — **`TODO(source-L31A-1)`** | null |
| C4 | Effective washing covers the **wrists, between the fingers, and under the nails**, then dries the hands | `[Waiver360-added]` | CDC handwashing technique; **not** APD-stated — **`TODO(source-L31A-2)`** | null |
| C5 | The CDC **"20-second"** scrub duration is **deliberately NOT stated in narration**; it appears only in the `V-L3-1-02` timer animation, which is flagged `[Needs Owner Review]` | `[Needs Owner Review]` | docs/42 field 7 ("*20 seconds* = CDC [Needs Owner Review]"); legacy SRC-1 open | null |
| C6 | Gloves do **not** replace hand washing | `[APD]`-aligned correction | Concept `common_misconceptions`; Mod2 hand-washing-before/after framing | null |
## Decision queue → owner / SME (Michele + Nicole)
1. **`[Needs Owner Review]` — CDC "20 seconds."** The narration deliberately omits the number
(docs/43 §15: a Needs-Owner-Review claim may not be locked into narration/KC keys). SME to confirm
the APD-aligned scrub duration for the med-admin context before (a) any narration states a number
and (b) the `V-L3-1-02` timer animation is finalized. **This is the item that gates a duration
claim to production.** (Legacy SRC-1 is still open.)
2. **`TODO(source-L31A-1)` — bathroom→soap+water example.** Confirm the *"right after helping a
client in the bathroom"* scenario is an acceptable `[Waiver360-added]` application of APD's
"visibly soiled → not sanitizer" rule (this drives the KC correct key). Until confirmed, C3 stays
`verified_by: null` and the KC key is preview-only.
3. **`TODO(source-L31A-2)` — washing technique.** Confirm *wrists / between fingers / under nails /
dry* as acceptable `[Waiver360-added]` CDC scaffolding, or replace with an APD-verbatim technique.
4. **Sanitizer ≥60% threshold.** Confirm the exact APD slide for the 60% figure (concept cites the
s51–52 family; pin the slide).
5. **Gate strength.** The concept calls for a *pre-flight "hands" gate before the MAR opens*. Because
clinical_risk is **Moderate→High (not Critical)**, a force-fail is **not** mandated (docs/42 §D.2).
Owner to confirm whether the gate is a **hard blocker** (MAR will not open until hands are done) or
a **soft warning** that logs. The sim rule currently encodes a blocking gate, not a force-fail.
6. **Superlative.** The legacy line "hand hygiene is the most proven way to prevent the spread of
infection" (SME-resolved 2026-06-30 in the frozen L3-1 doc) is **deliberately not carried** into
this fragment's narration. Owner to decide whether to re-approve the superlative for this bundle.
## Patient-safety chain
Owner directive: treat MA.L3-1.A as a patient-safety concept. The chain below is concrete and
specific to THIS concept (hand hygiene as Step 1 of every pass), not generic.
1. **Medication error prevented.** Cross-contamination — pathogens carried on your hands from one
client (or one soiling task, or one route) onto the medications and then into or onto the next
client. An infection your resident did not have before your med pass, spread by the hands that
prepared their dose.
2. **Why staff make this mistake (the real-world reason).** It is not "forgot." It is that
clean-*looking* hands *feel* clean. Right after you help a resident in the bathroom, your hands do
not look dirty, so grabbing the sanitizer bottle sitting on the cart feels fine — and it is faster
than walking to the sink. On a busy morning pass, soap-and-water feels like a detour. And gloves
*feel* like protection, so it is tempting to glove up and skip the wash. The mistake is trusting how
your hands look and feel over the rule — sanitizer-when-soiled, gloves-instead-of-washing, and the
quick rinse are all "close enough" shortcuts under time pressure, not carelessness.
3. **How the lesson/transcript prevents it.** Block `l31-wash-hands` makes hand-washing the first act of
every pass and names the soiled-hands exception out loud: right after the bathroom, sanitizer is
**not** enough — you wash with soap and water. It teaches the not-soiled case (an alcohol sanitizer of
≥60%), coaches where germs hide (wrists, between the fingers, under the nails, then dry), and ties the
act to the stake — clean hands are what stop germs moving from one client, or one route, to the next.
It deliberately does **not** assert a CDC "20-second" number (carried only by the flagged timer
animation) and does not carry the frozen superlative (Decision queue #1, #6).
4. **How the simulator reinforces it.** The `don-montana--hand-hygiene-gate` pre-flight gate blocks the
MAR from opening until the learner completes hand hygiene **and** chooses the correct method for the
presented context. There is no path to the pills around the gate; choosing sanitizer when the context
is soiled does not clear it — the learner is re-taught and retries. Because the concept is
Moderate→High (not Critical), the gate is a hard blocker, not a scenario force-fail.
5. **How the KC verifies mastery.** `KC-L3-1-A-Q1` drops the learner into the exact soiled context (just
helped a client in the bathroom) and forces the choice of soap-and-water over the three named
misconceptions modeled as distractors — sanitizer-when-soiled (a), gloves-instead (c), and the quick
rinse (d). Passing at the Moderate→High **≥80%** bar is the signal that the soiled-hands
discrimination — not just "wash your hands" — has actually landed.
## Bundle contents (this concept)
- `../blocks/l31-wash-hands.json` — transcript block (concept `transcript_blocks: l31-wash-hands`)
- `../knowledge-checks/KC-L3-1-A-Q1.json` — scenario MCQ (concept `knowledge_checks` #13)
- `../sim-rules/don-montana--hand-hygiene-gate.json` — pre-flight hands gate (concept `simulation_opportunities`)
- Storyboard frame `V-L3-1-02` (handwashing animation) is **referenced**, authored by the later
lesson-storyboard aggregation step (not in this bundle).
- **No exercise-type proposal**: the KC is a registered `mcq4`; the concept references no
unregistered interactive type.
You just finished helping a client in the bathroom. Before you prepare their medications, what must you do?
Why: Your hands may be soiled after helping in the bathroom, so hand sanitizer is not enough. When hands are soiled you wash with soap and water. That is Step 1 before you touch any medication -- it stops germs from moving from this client, or this task, to the next.
Error prevented: Cross-contamination / pathogen transfer -- carrying germs from a soiling task straight onto the medications and the next client or route.
Misconception: "Sanitizer is fine on visibly soiled hands", "gloves replace washing", and "a quick rinse counts."
Entry: Learner starts the Don Montana med pass. Before the MAR is rendered, a pre-flight 'hands' gate appears: the learner must complete hand hygiene to unlock the MAR.
Mastery: >=80% on the associated KC for entry; the gate itself is block-until-complete, not force-fail.
Shot: Open MS Michele at a med cart in a group-home kitchen; brand bug top-right. Cut to insert B-roll: hands at a sink, then a soap-vs-sanitizer decision card.
Camera: Eye-level medium shot, slow push-in on 'Step 1 of every med pass'; cut to overhead insert of the sink for the wash loop.
Avatar: Michele on-camera for the framing line; voiceover over the wash-loop B-roll.
Visual: Establish hand hygiene as the immovable first act of every pass before any medication appears; make the soap-vs-sanitizer choice a single clear decision (MA.L3-1.A visual_opportunities: soap-vs-sanitizer decision card).
Animation: Wash-loop animation of correct technique (wrists, between fingers, under nails, then dry) with an UNNUMBERED timer ring that fills once — NO scrub-second count rendered ([Needs Owner Review], TODO(source-L31A-1)). Decision card flips to the correct side as narration names the rule.
Infographic: Soap-vs-sanitizer decision card: left 'visibly soiled / after bathroom help → soap + water'; right 'not soiled → sanitizer, at least 60% alcohol'. Persistent 'Step 1' chip on the procedure rail.
Handwashing wash-loop with an unnumbered timer ring, plus a soap-vs-sanitizer decision card. Technique: wrists, between fingers, under nails, then dry.
🖼 image prompt: Flat-vector soap-vs-sanitizer decision card: left panel 'visibly soiled / after helping in the bathroom → soap and water'; right panel 'not soiled → alcohol sanitizer, at least 60%'; small hands-at-sink icon; neutral clinical palette; synthetic content only; no logos. [APD] Module 2 s51-52. Do NOT render any scrub-second number ([Needs Owner Review], TODO(source-L31A-1)).
🎬 video prompt: Looping wash animation showing wrists, between the fingers, under the nails, then drying; an UNNUMBERED circular timer ring fills once around the hands (no digits, no second count rendered); decision card flips to the correct side as the rule is stated; transparent background; no camera move. [APD] wash technique; scrub duration deliberately omitted ([Needs Owner Review]).
Target runtime: 4:30 · 7 chapters · not rendered (url: null)