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Session 3 · Frame 1 of 10
The order is placed. Has the care happened?
72 years old; recently hospitalized with HF
CKD, type 2 diabetes and multiple prescriptions
Different teams own different parts of the list
Fictional AI-generated scene; not patient testimony.Facilitator notes
Use the fictional kitchen-table scene to introduce Teresa’s confusion, not as evidence of a real patient outcome. She has a discharge list, pharmacy instructions and an upcoming appointment. Ask who is responsible for reconciling what she actually takes. Invite the audience to identify one failure that can occur even when every individual order is technically correct.
Use the three pre items before displaying the safety algorithms. Preserve first responses and count missing values separately. Explain that the cases test recognition and coordination, not memorization of every prescribing-table cell. The host should distinguish anonymous audience questions from learner assessment records and should never solicit identifiable patient cases in open chat.
Have the pharmacist ask Teresa to describe each medicine in her own words. Then have the primary-care clinician identify which discrepancies require same-day clarification. Avoid treating an electronic medication list as evidence that a medicine was obtained or taken. Include nonprescription products and newly prescribed interacting medicines. Identify the clinician responsible for resolving each unresolved discrepancy.
A reassuring glucose number does not resolve the danger
Facilitator notes
Pause and ask the panel to state an action before naming the diagnosis. Explain that SGLT2-associated ketoacidosis may occur without marked hyperglycemia. Temporarily stop the medicine and arrange urgent assessment for ketoacidosis, depletion and other acute illness. Do not teach home observation or waiting for the routine panel as the default response to this symptom pattern.
Review the result, contributing factors and full eligibility
Facilitator notes
Emphasize the timing: initiation and continuation rules are not interchangeable. A clinician may remember a higher withholding threshold from a titration table and incorrectly use it to start therapy. Ask the pharmacist to explain the difference and how the team will communicate the change to Teresa and the pharmacy. The complete current label controls dose changes; this slide is a decision aid, not a substitute for it.
When eligible, pair the dose with a monitoring task
HF potassium/eGFR check at four weeks after starting or dose change
Earlier assessment when clinical circumstances require
Named reviewer and patient-contact plan
Facilitator notes
Ask the audience to name the last step in the task. It is not ordering a laboratory panel. It includes completion, review, an action when needed and communication with the patient. Show how the planned date, location and responsible clinician fit into the discharge or outpatient note. Discuss how coverage is handled if the named clinician is unavailable.
Keep the task open until reviewed and communicated
Facilitator notes
Present three practical explanations: the patient did not attend, the result is at another system, or the result arrived but was not routed. Ask the panel for a specific response to each. An automated reminder can assist, but cannot establish that the test occurred. Explain escalation for a persistent missing result based on therapy and clinical risk; do not assign an arbitrary universal delay.
Who will call, and which symptoms need immediate help?
Facilitator notes
Invite a brief role-play between the moderator and pharmacist. Ask the audience which wording is easier to act on. The learner should leave able to describe a closed-loop handoff with a date and owner. Do not require a written assignment or patient disclosure. Include support for language, health literacy, disability and access as practical care-planning considerations.
What if the receiving clinician has not accepted the handoff?
What if a medicine is unaffordable?
Which symptoms bypass routine follow-up?
Facilitator notes
Reserve ten minutes for audience barriers and questions. Discuss respectful escalation across teams rather than transferring responsibility through an unacknowledged message. For new resting chest pressure, severe dyspnea, syncope or other instability, urgent assessment supersedes the routine pathway. Keep individualized treatment advice out of the public session; teach the reasoning and referral threshold.
At 60 days, reassess competence and implementation barriers
Facilitator notes
Collect the post cases before showing the key. Distinguish competence from self-reported behavior: a correct case response demonstrates application in an assessment, while a later report of practice change is not verified patient care. Invite consent for the host follow-up under its privacy policy. Summarize the task: test, date, owner, action and patient communication.
