Lesson L3-2 · authored fragments (docs/43)
Primary review content — the AI-avatar narration, in order.
Let's talk about liquid medicines and small doses — the ones that are easy to get wrong on a busy shift. First, suspensions. A suspension is a liquid where the medicine is mixed in but doesn't stay mixed. When the bottle sits on the cart, the medicine slowly settles to the bottom. If you pour without shaking, the first doses come out too weak and the last doses come out too strong — same bottle, wrong dose for your resident. So make shaking your default: shake the bottle well before every pour. Don't wait for the label to tell you. Many of these settle, and a good shake first protects your resident every time. Now small doses. When you need less than about 5 mL, or any time the dose has to be exact, reach for an oral syringe. That's a good habit — a best practice. Draw the liquid up to the mark on the barrel, then push out any air, so the number you see is the real dose. If the bottle came with an adapter, use it — it makes the draw more accurate and keeps the tip clean. And dilution. Some liquids have to be mixed or watered down before you give them. If the label says to dilute, do exactly what it says — the exact liquid, the exact amount. Never improvise, and never dilute just to make it pour easier. If the label doesn't say to, don't. And any time you're not sure, stop and ask the nurse or pharmacist. That's always the safe move.
16 of 16 critical claims are verified_by: null (Gate-2 SME sign-off pending → preview only, production-blocked under the Rule-3.6 waiver). · runtime budget: 12:00
# Concept mirror — MA.L3-2.E (Oral Syringe & Suspensions — shake, dilute)
> **MIRROR / NOTES ONLY.** The authoritative concept entry is **docs/42 §E, `MA.L3-2.E`**
> (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.E` |
| `competency_id` | `C-3.2` |
| `lesson_ids` | `[L3-2]` |
| `clinical_risk` | **High** (unshaken suspension → uneven dose) / **Moderate** (device choice) — ≥90% KC mastery, spaced repetition; NOT Critical (no 100%-gate, no force-fail, no SME-protected key) |
| `medication_error_prevented` | An uneven dose from an unshaken suspension, or an over/underdose from measuring a small liquid volume with an imprecise tool or improvising dilution |
| `sme_status` | `in_review` |
| `apd_traceability_status` | waiver360_added — shake/dilute/device are `[APD]` (Module 2 s66); the oral-syringe device, the "<5 mL" threshold, and bottle adapters are `[Waiver360-added]` best practice (owner-approved 2026-07-05) |
## 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_*`.
## Patient-safety chain (owner directive — this is a patient-safety concept)
1. **Medication error prevented.** An *uneven or inaccurate dose*. Two ways it happens: (a) a suspension
is poured without shaking — the drug settled to the bottom of the bottle, so the early doses are too
weak and the last doses too strong (same bottle, wrong dose); (b) a small liquid volume (e.g. 2.5 mL)
is measured with a tool too imprecise for the amount, or the liquid is diluted the wrong way.
2. **Why staff make this mistake (the real reason).** On a busy med pass a suspension *looks* already
mixed, so shaking feels optional and gets skipped. For tiny doses, staff grab whatever is handy —
a medicine cup or even a spoon — because "2.5 mL is basically nothing," not realizing small volumes
are exactly where a cup is least accurate. And older training literally taught "shake only if the
label says," which is backwards for the suspensions this population takes.
3. **How the lesson/transcript prevents it.** Block `l32-oral-syringe` teaches shake-is-the-**default**
(suspensions settle when the bottle sits), draw-to-the-mark with an oral syringe and push out the air
for small/precise doses (badged as best practice), and dilute **only** exactly as the label says —
never improvise.
4. **How the simulator reinforces it.** The optional Don Montana precision-draw micro-step makes the
learner *shake first*, then draw the liquid suspension to the mark and expel the air before charting;
skipping the shake or misdrawing triggers coaching (non-force-fail — this concept is High, not Critical).
5. **How the KC verifies mastery.** `KC-L3-2-E-Q1` checks the shake-first default against the "shake only
if told" and "improvise dilution" misconceptions; `KC-L3-2-E-Q2` checks correct tool choice (oral
syringe, best practice) for a small precise dose against imprecise-tool and dangerous-tool distractors.
## Source ledger (projects into `payload_json.sources`)
- `curriculum_source`: "APD BMA Module 2 (liquid measurement & suspensions, s66) + [Waiver360-added] ISMP/USP oral-syringe best practice (owner-approved 2026-07-05)"
- `form_reference`: "APD Form 65G-7.008 A (MAR)"
| # | Claim | Tag | Source | verified_by |
|---|---|---|---|---|
| C1 | Suspensions settle when the bottle sits; shake the bottle **well before pouring** so the dose is even — shaking is the **default**, not "only if told" | `[APD]` | Module 2 s66 ("Shake the bottle before pouring – many medications settle"); checkpoint v4 Q21 | null |
| C2 | Measure a liquid dose with the **device that came with the medication** | `[APD]` | Module 2 s66 | null |
| C3 | Some liquids must be **diluted before giving**; follow the label exactly (amount + type of diluent); do not improvise, and do not dilute when the label does not say to | `[APD]` | Module 2 s66 family — **`TODO(source-L32-E1)`** (DSP dilution-scope boundary unresolved) | null |
| C4 | For doses **under ~5 mL** or when precision matters, an **oral syringe** drawn to the mark with the air expelled is the best tool; a **bottle adapter** improves accuracy and protects the tip | `[Waiver360-added]` | ISMP/USP best practice; owner-approved 2026-07-05 (docs/42 §I.3.1) — **NOT APD-required** | null |
| C5 | If unsure whether/how to dilute, **stop and ask the nurse or pharmacist** | `[APD]` | Module 2/Module 3 escalation principle (legacy L3-2 block-05) | null |
## Decision queue → owner / SME (Michele + Nicole)
1. **`TODO(source-L32-E1)` — DSP dilution scope.** Confirm *when a MAP/DSP may dilute per label* vs.
*when dilution requires a nurse or pharmacy*. Until resolved, C3 stays `verified_by: null` and the
bundle stays preview-only on the dilution claim. **This is the item most likely to gate the concept
to production.**
2. **Confirm the shake-is-default wording (C1).** Legacy carried `TODO(M+N — L32-R02)`: the prior
"shake only if the label tells you to" wording was backwards; the corrected wording maps to Module 2
s66 + checkpoint v4 Q21. SME to verify the exact APD-aligned phrasing before C1 is verified.
3. **Confirm the best-practice badge treatment (C4).** The oral-syringe / "<5 mL" / bottle-adapter
guidance is owner-approved as `[Waiver360-added]` best practice (§I.3.1) and may appear in narration
+ KC keys — but **never implied APD-required**. Confirm the **visual best-practice badge** on frame
`V-L3-2-07` and that the narration/KC framing reads as a good habit, not an APD rule.
4. **Confirm the optional sim micro-step (concept item 12).** The Don Montana precision-draw micro-step
runs **only if the syringe content clears owner review**. Confirm inclusion and confirm the synthetic
liquid-suspension med used for the micro-step.
## Deferred remediation variants (owner decision — DEFERRED until full route is done)
`KC-L3-2-E-Q1B`, `KC-L3-2-E-Q2B` are referenced by remediation `onWrong` but **not authored** in this
bundle; the aggregator records them in the manifest `deferred_variants`.
## Bundle manifest / README owned by a later aggregation step (not authored here).
A liquid suspension has been sitting on the med cart since the last pass. Before you pour your resident's dose, what should you do?
Why: A suspension settles when it sits — the medicine drifts to the bottom of the bottle. Shaking well before every pour mixes it back so the dose is even. Shaking is your default; you don't wait for the label to tell you.
Error prevented: An uneven dose from an unshaken suspension — the resident's early doses too weak and later doses too strong out of the same bottle.
Misconception: "Shake only if the label tells you to" and "improvise dilution."
Your resident's order is 2.5 mL of a liquid antibiotic, and the dose has to be exact. Which tool is the best choice?
Why: Best practice (a Waiver360 best-practice habit, not an APD rule): for doses under about 5 mL or when precision matters, an oral syringe drawn to the mark with the air pushed out gives the most accurate dose. APD's requirement is to use the device that came with the medication; the oral-syringe and '<5 mL' guidance is best practice on top of that.
Error prevented: An over- or under-dose of a small-volume liquid from a tool too imprecise (or too dangerous) for the amount.
Misconception: "A medicine cup is precise enough for tiny doses" and "any syringe or spoon will do."
Entry: Learner reaches the optional liquid micro-step in the Don Montana MAR Simulator and must give a small-volume liquid suspension dose.
Mastery: ≥90% competency target with spaced repetition; NO 100% gate, NO force-fail (this concept is not Critical).
Shot: A suspension bottle settling (separated layers), then an even mix after a shake; cut to an oral syringe drawing to a mark with a best-practice badge.
Camera: Hold on the settled bottle to show separation; whip to the shaken, even mix; macro on the syringe draw-to-the-mark and the expelled air bubble.
Avatar: Voiceover; badge tone - the syringe segment is best practice, spoken as 'a good habit', never as an APD requirement.
Visual: 'Settles when it sits' - separation then even mix after a shake (shake is the DEFAULT for suspensions); the oral-syringe / '<5 mL' precision draw carries a [Waiver360-added] best-practice badge, never APD-required.
Animation: The suspension separates when still, then blends evenly after a shake; the syringe draws to the mark and expels the air bubble; the best-practice badge fades in visually distinct from the [APD] chips.
Infographic: Chip 'Shake suspensions first - every time' [APD]; a distinct badge 'Best practice (Waiver360) - oral syringe for small/precision doses, <5 mL' [Waiver360-added]; 'dilute only per the label'.
Suspension settling-then-shaking sequence plus an oral-syringe precision draw carrying a Waiver360 best-practice badge.
🖼 image prompt: Flat-vector sequence: a suspension bottle with visibly separated layers when still, then an even, uniform mix after shaking; beside it an oral syringe drawn to a marked line with an expelled air bubble; an [APD] chip 'Shake suspensions first - every time' rendered separately from a visually distinct badge 'Best practice (Waiver360): oral syringe for small/precision doses (<5 mL)'; a 'dilute only per the label' chip; neutral clinical palette; synthetic props. Shake [APD] Mod2 s66 family; syringe/'<5 mL' [Waiver360-added] best practice, never shown as APD-required.
🎬 video prompt: A suspension separates when still, then blends evenly after a shake; an oral syringe draws to the mark and expels the air bubble; the best-practice badge fades in visually distinct from the [APD] chips and is never labeled APD-required. [APD]+[Waiver360-added]
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