MA.L3-2.C

# Concept mirror — MA.L3-2.C (The Crush Rule — enteric-coated & extended-release)

> **MIRROR / NOTES ONLY.** The authoritative concept entry is **docs/42 §E, `MA.L3-2.C`**
> (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.L3-2.C` |
| `competency_id` | `C-3.2` (⇄ `C-3.3` / `MA.L3-3.B` — crush rule recurs for mixers & G-tube) |
| `lesson_ids` | `[L3-2]` + cross-cutting (`L3-3` mixers, enteral-route lesson — the rule recurs for G-tube) |
| `clinical_risk` | **Critical** → 100% KC mastery, sim force-fail, SME-protected KC keys |
| `medication_error_prevented` | An enteric-coated or extended-release form crushed / split / opened → the whole timed dose released at once → overdose / toxicity |
| `learning_objective` | *Know* EC/ER must never be crushed/split/opened; *do* recognize the labeling and STOP + contact the prescriber when the ordered form can't be swallowed |
| `transcript_blocks` | `l32-do-not-crush` (single block) |
| `storyboard_references` | `V-L3-2-04`, `V-L3-2-05` |
| `knowledge_checks` | `KC-L3-2-C-Q1` (100%-gating multi-select); inverted variant `Q1B` **deferred** (owner decision 2026-07-05) |
| `simulation` | Don Montana Diltiazem ER — choosing the crusher is a **force-fail critical error** |
| `sme_status` | `in_review` |
| `apd_traceability_status` | sourced (suffix list = `[Waiver360-added]`; one `[Needs Owner Review]` on the escalation target) |

## 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 reference build.
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_*`. Because this concept is **Critical / 100%-gating**, the
KC answer key and the sim force-fail rule are additionally **SME-protected copy** (docs/42 §D.2,
docs/43 §7): changing the correct answer is a new item version, never an in-place edit.

## Source ledger (projects into `payload_json.sources`)

- `curriculum_source`: "APD BMA Module 2 (oral forms & the crush rule) + APD MAR practical exam (Don Montana med pass, Diltiazem ER)"
- `form_reference`: `null` — the crush rule is not tied to a specific APD form; it recurs on the MAR (65G-7.008 A) and on the enteral/G-tube MAR.

| # | Claim | Tag | Source | verified_by |
|---|---|---|---|---|
| C1 | Enteric-coated and extended-release ("long-acting") medications should not be crushed, split, or opened; altering the ordered form requires a prescriber order | `[APD]` | Mod2 s118 ("must have an order to crush, dissolve, or dilute… enteric coated (like some aspirin) and long-acting should not be crushed"); s59 | null |
| C2 | Crushing/opening an EC/ER form releases the whole timed dose at once instead of slowly → the client can get all of it at once, which can be very harmful (overdose/toxicity) | `[APD]` (mechanism) + `[Waiver360-added]` (DSP-register consequence phrasing) | Mod2 s118 + instructional rationale | null |
| C3 | When the client cannot swallow the ordered form, the MAP STOPS and contacts the prescriber for a different form — the MAP may **not** change the form themselves | `[APD]` | Mod2 s118; checkpoint Mod2 v2 Q25 (Procardia XL "take whole" → escalate). **`TODO(source-L32C-1)`** (see C6) | null |
| C4 | The recognition suffixes **EC / DR / ER / XR / SR / CR** (and the words delayed/extended/sustained release) mark do-not-crush forms | `[Waiver360-added]` | Instructional recognition aid; docs/42 field 7 explicitly tags the suffix list as Waiver360-added, not APD-stated | null |
| C5 | Mixing a crushed EC/ER med into food (e.g., applesauce/pudding) does **not** bypass the rule — it is still crushing | `[Waiver360-added]` | Instructional decomposition of C1; ties to the MA.L3-3.B applesauce error | null |
| C6 | Escalation target wording: the concept says "contact the **prescriber**"; APD checkpoint Mod2 v2 Q25 keys "call the **pharmacist**" | `[Needs Owner Review]` | Concept field 4 vs. Mod2 v2 Q25 answer key — unresolved wording tension | null |

## Patient-safety chain (owner directive — Critical concept)

1. **Medication error prevented.** A MAP crushes, splits, or opens an enteric-coated or extended-release
   pill (or empties its beads into applesauce). The coating/time-release design is destroyed, so a dose
   engineered to release over hours hits the resident all at once — an overdose/toxicity event from a
   correctly-prescribed medication.
2. **Why staff make this mistake — the real-world reason.** It is almost never "forgot." The resident
   genuinely can't swallow the big pill (dysphagia, a bad swallow day, or a G-tube), the med pass is
   running behind, and crushing it into applesauce looks like the *kind, helpful* thing to do — the MAP
   is trying to get the dose **in**, not skip it. And the harm is invisible: the crushed pill looks the
   same, the resident swallows it fine, and nothing bad happens in the room that shift — so the shortcut
   *feels* safe and gets repeated until the day it isn't.
3. **How the lesson/transcript prevents it.** Block `l32-do-not-crush` replaces "use your judgment" with
   one hard rule. It gives the **recognition cue** (the EC/ER labeling + a plain-language picture of the
   coating and the slow-release beads and *why* they exist) and the **single correct action** — STOP and
   contact the prescriber for a different form — and it names the food-mixing loophole out loud so it
   can't be rationalized.
4. **How the simulator reinforces it.** In the Don Montana scenario the resident's Diltiazem is an
   extended-release capsule he says is hard to swallow. Reaching for the pill crusher (or opening the
   capsule / stirring the beads into applesauce) is a **force-fail critical error** — the scenario will
   not advance until the MAP escalates instead of altering the form. The safe-in-the-room feeling is
   replaced by an immediate, unmistakable stop.
5. **How the KC verifies mastery.** `KC-L3-2-C-Q1` is a 100%-gating multi-select: even when a prescriber
   has ordered the meds crushed into applesauce, the MAP must **not** select the enteric-coated and
   extended-release items. Any inclusion of an EC/ER form is a miss, blocks progression, and routes to
   remediation — mastery is "recognize EC/ER and refuse to alter them," verified under a realistic
   crush-order pressure.

## Decision queue → owner / SME (Michele + Nicole)

1. **`TODO(source-L32C-1)` — escalation target (C6): prescriber vs. pharmacist.** The concept (docs/42
   field 4) says "contact the **prescriber**"; the APD checkpoint Mod2 v2 Q25 keys "call the
   **pharmacist**." Narration currently follows the concept ("prescriber") because docs/42 is the
   authority, but this is a `[Needs Owner Review]` tension and may not be locked as an APD-verbatim
   escalation target until resolved. **SME to confirm the correct Florida-APD escalation contact for a
   MAP.** Until then C3/C6 stay `verified_by: null` and the bundle is preview-only.
2. **Confirm the suffix list (C4).** Is `EC / DR / ER / XR / SR / CR` acceptable as a
   `[Waiver360-added]` recognition aid in narration (labeled as such), given the KC answer key leans on
   the plain APD terms "enteric-coated" / "extended-release" rather than the suffix decode?
3. **KC 4th-option decision (Option B).** The chewable-multivitamin option is **removed**
   (owner-approved 2026-07-05). The legacy TODO proposed replacing it with an unlabeled-bottle
   STOP-and-ask escalation distractor. This bundle keeps `KC-L3-2-C-Q1` at **three fully-APD-sourced
   options**; SME to decide whether to add the escalation distractor as a fourth option.
4. **Confirm the consequence register (C2).** Narration uses "the client can get all of it at once —
   that can make them very sick." Legacy guidance forbids "fatal overdose"/"could kill." Confirm this is
   the right register for the DSP audience, or supply preferred wording.
5. **Variant `KC-L3-2-C-Q1B` is deferred** (owner decision: remediation variants deferred until the full
   route is authored). `remediation.onWrong` references it as "(deferred — authored on concept
   approval)"; the aggregator must record `KC-L3-2-C-Q1B` in the manifest `deferred_variants` so the
   remediation path is never a silent dead-end.

## Bundle manifest → `../MA.L3-2.C.manifest.json` · human index → `../MA.L3-2.C.README.md` *(owned by the later aggregation step)*