Lesson L3-2 · authored fragments (docs/43)
Primary review content — the AI-avatar narration, in order.
Let's put it all together. Four mistakes show up again and again on oral med passes — and every one of them lands on your resident. I want you to know all four cold, because on a busy shift they don't feel like mistakes. They feel like little shortcuts. Number one: changing a pill that must not be changed. Some pills are built to release their dose slowly, over hours. Your MAR or the label will tell you: do not crush. If your resident can't swallow it, you don't crush it, you don't open it, and you don't hide it in pudding. You STOP and you ask. Crush that pill and the whole dose hits at once — that's an overdose. Number two: measuring a liquid with the wrong thing. That spoon from the break-room drawer is not a measuring tool. Use the cup or the device the medication came with. The wrong tool means the wrong dose — too much or too little. Number three: walking away before your resident swallows. Handing over the cup is not the same as giving the medication. Stay. Watch her swallow. Turn to the next resident too soon and that dose can end up in a pocket, on the floor, or saved for later — and you just initialed a dose that never went in. Number four: waiting to write it down. "I'll initial the whole MAR at the end of my shift" is how a dose gets given twice, or missed. Initial the MAR right after the dose. Right then. Every time. Here's what I want you to carry with you: these errors are not rare, and they are not someone else's job to catch. You are the last set of eyes before the medication reaches your resident. The last chance to catch the error rests in your hands. Four errors, four habits — don't alter a do-not-crush form, use the right device, watch her swallow, chart it right away.
17 of 17 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.G (Four Common Oral-Route Errors — capstone)
> **MIRROR / NOTES ONLY.** The authoritative concept entry is **docs/42 §E, `MA.L3-2.G`**
> (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.G` |
| `competency_id` | `C-3.2` |
| `lesson_ids` | `[L3-2, L4-1]` (capstone in L3-2; reused as an error-cause frame in L4-1) |
| `clinical_risk` | **High** overall — but it summarizes the **Critical** crush rule (MA.L3-2.C); the crush-error KC key is SME-protected + the sim crush event is force-fail |
| `medication_error_prevented` | Any of the four recurring oral-route errors going unrecognized: crush-wrong-form (overdose), wrong-tool measurement (over/underdose), unobserved intake (unaccounted/missed dose), documentation lag (double-dose or missed dose) |
| `sme_status` | `in_review` (docs/42) → all derived fragments `draft` |
| `apd_traceability_status` | waiver360_added (framing); the four underlying error-claims each trace to a sibling concept's APD source; two open anchors (`TODO(source-L32G-1)`, `TODO(source-L32G-3)`) |
## 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 — treat MA.L3-2.G as a patient-safety concept)
1. **Medication error prevented.** Any of the four recurring oral-route errors reaching the resident:
a do-not-crush form altered (whole dose dumped at once → **overdose**), a liquid measured with a
kitchen spoon (**wrong dose**), a dose handed over but not swallowed (**unaccounted / missed
dose**), or documentation delayed to end of shift (**double-dose or missed dose** on the next
pass). This concept exists so a new MAP *recognizes* each one in the moment.
2. **Why staff make this mistake (the real reason).** Not "forgot." A brand-new MAP sees each of
these as a small, harmless shortcut under time pressure — "just this once I'll sprinkle it in the
pudding," "the break-room spoon is close enough," "I'll chart the whole MAR at the end." They
don't connect the everyday shortcut to the specific harm, and they believe errors are rare and
someone else's problem to catch. The shortcut *feels* like good service, not a mistake.
3. **How the lesson/transcript prevents it.** The `l32-common-errors` capstone names all four in
plain "here's what this looks like on your shift" language and welds each error to **one**
prevention habit, so the shortcut and its consequence are stored together in memory — and it
ends on "you are the last set of eyes; the last chance rests in your hands."
4. **How the simulator reinforces it.** The Don Montana oral-pass **debrief** maps every flagged
error event back to one of the four and makes the learner name it; the **crush event force-fails**
so the highest-harm shortcut (crushing the Diltiazem ER) can never be quietly passed through.
5. **How the KC verifies mastery.** Four scene-based "which error is happening here?" items — one per
error — prove the learner can *spot* the error in the wild, not just recite the list. The
crush-error item's key is SME-protected (it guards the Critical MA.L3-2.C rule).
## Source ledger (projects into `payload_json.sources`)
- `curriculum_source`: "APD BMA Module 3 error section ('the last chance rests in YOUR hands', s29) synthesized with the C-3.1/C-3.2 oral-route concepts. Waiver360-added capstone framing."
- `form_reference`: "APD Form 65G-7.008 A (MAR)"
| # | Claim | Tag | Source | verified_by |
|---|---|---|---|---|
| C1 | The four recurring errors = crush-wrong-form · wrong-device measurement · unobserved intake · documentation lag | `[Waiver360-added]` | Synthesis of Mod3 error section + C-3.1/C-3.2 — **`TODO(source-L32G-1)`** (confirm the enumeration matches APD's most-common-errors framing) | null |
| C2 | Enteric-coated / extended-release must never be crushed, split, or opened (whole dose at once → overdose) | `[APD]` | Module 2 s118 (⇄ Critical MA.L3-2.C) | null |
| C3 | Measure a liquid with the supplied device / medicine cup; never a household spoon | `[APD]` | Module 2 s66, s67 (⇄ MA.L3-2.D) | null |
| C4 | Watch the resident swallow before documenting; handing over the cup ≠ dose taken | `[Needs Owner Review]` | Oral-route procedure (MA.L3-1) — **`TODO(source-L32G-3)`** (confirm exact APD observe-swallow slide) | null |
| C5 | Initial the MAR immediately after the pass, not at end of shift | `[APD]` | Module 1 s71 (⇄ MA.L3-1.F / C-2.8) | null |
| C6 | The MAP is the last check — "the last chance to catch the error rests in your hands" | `[APD]` | Module 3 s29 | null |
| C7 | "These errors are common and are your job to catch — not rare, not someone else's problem" (misconception target) | `[Waiver360-added]` | Instructional framing of the C1 synthesis; not APD-verbatim | null |
## Decision queue → owner / SME (Michele + Nicole)
1. **`TODO(source-L32G-1)` — confirm the four-error enumeration.** The capstone names exactly four
errors and pairs each with one habit. Confirm this matches APD BMA Module 3's most-common-errors
framing (does APD name a list, and is it these four?), or accept it as `[Waiver360-added]`
instructional synthesis. Gates C1; keeps the bundle preview-only until resolved.
2. **`TODO(source-L32G-3)` — confirm the observe-swallow APD anchor.** Error #3 ("leaving before the
resident swallows") is treated as `[Needs Owner Review]` pending the exact APD BMA slide for
observed oral administration (expected in the MA.L3-1 procedure concept). Until confirmed it may
not be locked as an APD claim in narration or the KC key — it is carried as a critical_claims
entry with `verified_by: null`.
3. **Crush-error KC key protection.** Per the 2026-07-05 locked decision, the crush rule (MA.L3-2.C)
is Critical / 100%-gating. `KC-L3-2-G-Q1` (identify the crush error) is authored `keyProtected:
true` even though MA.L3-2.G itself is High-risk, because that item guards the Critical crush
concept. Confirm this protection scope is acceptable, or scope the 100%-gating strictly to the
MA.L3-2.C bundle.
4. **Wrong-device answer key (Q2).** The correct answer is keyed to the **APD** claim ("kitchen spoon
is the wrong device," Mod2 s66) — **not** to the Waiver360-added "<5 mL oral syringe" best
practice (MA.L3-2.E §I.3.1). Confirm the item never implies the syringe threshold is APD-required.
## Bundle manifest + storyboard + README are owned by the later aggregation step (docs/43 §18).
A resident can't swallow a large pill. It is an extended-release capsule. To help it go down, the MAP opens the capsule and stirs the little beads into a cup of pudding. Which of the four oral-route errors is happening here?
Why: Opening an extended-release capsule is altering a do-not-crush form — mixing the beads into pudding does not make it safe. The dose that was built to release over hours now hits the resident all at once. The habit that prevents it: when a form says do-not-crush, STOP and ask the prescriber; never crush, open, or hide it in food.
Error prevented: An extended-release dose released all at once (overdose/toxicity) because the capsule was opened to make it easier to swallow.
Misconception: "Mixing a do-not-crush med into food makes it safe" and "errors are rare / someone else's problem."
A liquid antibiotic is ordered. Instead of the measuring cup that came with the bottle, the MAP grabs a teaspoon from the break-room drawer, fills it, and gives the dose. Which of the four oral-route errors is happening here?
Why: A break-room teaspoon is not a measuring tool — kitchen spoons vary in size, so the dose is guesswork. Use the cup or device the medication came with. The habit that prevents it: measure every liquid with the supplied device, never a household spoon.
Error prevented: An over- or under-dose from measuring a liquid with an inaccurate household spoon instead of the supplied device.
Misconception: "A teaspoon is a teaspoon" / "any spoon is close enough" and "errors are rare / someone else's problem."
The MAP hands a resident her pill cup, sets it on the table beside her, and steps out to start the next resident's pass. Which of the four oral-route errors is happening here?
Why: Handing over the cup is not the same as the medication being taken. If the MAP walks away, that dose can end up in a pocket, on the floor, or saved for later — and it may be charted as given when it never went in. The habit that prevents it: stay and watch the resident swallow before you move on.
Error prevented: An unaccounted or missed dose — the resident does not actually take the medication, but it is treated (and possibly charted) as given.
Misconception: "Handing over the medication counts as giving it" and "errors are rare / someone else's problem."
The MAP finishes the whole morning med pass for every resident, then decides to sit down and initial the entire MAR later, at the end of the shift, when there is more time. Which of the four oral-route errors is happening here?
Why: Charting the whole MAR at end of shift is how a dose gets given twice or missed — the next MAP can't tell what was already given, and hours of memory blur together. The habit that prevents it: initial the MAR right after each dose, every time.
Error prevented: A double-dose or a missed dose caused by delayed documentation — the next MAP cannot tell what was already given.
Misconception: "I can catch up the MAR at the end of my shift" and "errors are rare / someone else's problem."
Entry: End of the Don Montana oral med pass (post-pass debrief screen). Any oral-route error event flagged during the pass is presented for classification.
Mastery: Crush event: 100% / force-fail. Other three: pass on correct classification; repeat error routes to lesson replay.
Force-fail: FORCE-FAIL (inherited from MA.L3-2.C). The pass cannot complete with the crush event uncorrected; the sim surfaces the same compassionate-framing modal as KC-L3-2-G-Q1 with a link to the l32-common-errors 'error #1' re-anchor and a 'Try again' CTA. The debrief never silently passes a crush event through.
Shot: Four-error card grid; each error icon links by a line to its prevention concept; close on Michele on-camera with the disclaimer footer.
Camera: Reveal the four cards one at a time; on each, a red state flips to green; return to a centered medium shot of Michele for the sign-off.
Avatar: Michele on-camera for the capstone and close ('these errors are common, and catching them is your job'); calm, encouraging close.
Visual: Four-error card, each icon linking to its prevention concept - a [Waiver360-added] synthesis (TODO(source-L32G-1)); pair each error with exactly one prevention habit; the crush error inherits the Critical force-fail from MA.L3-2.C.
Animation: Each error card flips red->green to its prevention step; the crush card carries a red force-fail marker inherited from don-montana--crush-forcefail; a closing capstone chip fades in.
Infographic: Four cards: 'Crush the wrong form -> follow the label/order' (crush guarded, keyProtected), 'Wrong device -> mL device, never a kitchen spoon', 'Unobserved intake -> confirm the resident takes it', 'Documentation lag -> chart right away'; disclaimer footer 'APD-aligned educational content. Not an APD-approved training program.'
Four-error capstone card; each error icon flips red->green to its prevention concept; crush card inherits the Critical force-fail.
🖼 image prompt: Flat-vector four-card capstone grid: 'Crush the wrong form -> follow the label/order', 'Wrong device -> use the mL device, never a kitchen spoon', 'Unobserved intake -> confirm the resident takes it', 'Documentation lag -> chart right away'; each card has an icon and a connector line to its prevention step; a disclaimer footer 'APD-aligned educational content. Not an APD-approved training program.'; neutral clinical palette; synthetic props. Four-error framing [Waiver360-added] (TODO(source-L32G-1)); observe-swallow depicted generically (TODO(source-L32G-3)); wrong-device keyed to 'household spoon' [APD] Mod2 s66, never to the [Waiver360-added] '<5 mL' threshold.
🎬 video prompt: Each of the four cards flips red->green to its prevention step; the crush card carries a red force-fail marker inherited from don-montana--crush-forcefail; a closing capstone chip and the compliance disclaimer footer fade in. [APD]+[Waiver360-added]
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