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Medication

Medication

Handling and Administration of Medication

Each school district should have policies governing the handling and administration of medication that is in accordance with all other applicable state and federal laws and rules regarding medications. These policies regarding medication should require a signed licensed medical provider’s order and written parental consent.

Licensed medical provider’s orders should include the student’s name, date, the medication, dosage and possible side effects. Any order for an “as needed” (PRN) prescription must be accompanied by very specific instructions from the licensed medical provider.

It is recommended that school district medication policies require:

  • Current, signed parent or guardian consent
  • Current, signed licensed medical provider’s order
  • Properly labeled pharmaceutical container
  • Initial dose to be administered at home, licensed medical provider’s office or hospital
  • Renewal of parent/guardian consent and licensed medical providers order at the start of each school year
  • Plan for any required training (including merely informing)
  • Clear statement of supply responsibility
  • Strategy for dealing with problems caused by failure to receive medical supplies that parents/guardians are responsible for providing
  • Emergency plan consistent with school’s general emergency plan
  • Medication should be stored under proper temperature and maintained in a locked storage

 

Medication Issues- Common Questions and Answers

 Q. What is the school’s responsibility if the parent does not meet their responsibility of providing required medical supplies or medications?

A. First, meet with the parents to try to resolve the situation. If the problem persists and there is a safety risk to the student, the school should call the Department of Public Health and Human Services (DPHHS).

 Q. Is a school district responsible for purchasing and supplying medication?

A. No. It is the parents’ responsibility to purchase and supply the medications for their student at school.

 Q. Does the school have a responsibility for ensuring that a student remembers to take medication at school?

A. Not necessarily. However, a student’s age and disability may be factors the school needs to consider when developing the student’s health care plan. For some students there may need to be procedures implemented to help ensure the student receives needed medications.

Q. Is it permissible to change the dosage of medication at the request of a parent, even though the licensed medical provider’s (with prescriptive authority) order on the medication is different?

A. No. If the dosage of medication is to be changed, it must be changed by a licensed medical provider.

 Q. Can the school require a parent to have a student placed on medication in order to attend school?

A. No. However, if in the judgment of the nurse who provides services in the school, a student’s life or health is in danger without medication, adequate steps should be taken to inform the parents and encourage them to seek medical care.

 Q. When is it appropriate for a student to perform self-administration of medication?

A. The school should consider all of the following factors when allowing a student to self-administer medication:

1. Licensed medical provider recommendation;

2. The student’s competency and age to perform the procedures; and

3. The school district policy on self-administration and controlled substance.

What Can Be Delegated

The following activities are not the sole practice of nursing, and therefore do not require delegation. These activities may be performed by anyone trained to do so.

Assisting with medications by:

  1. Prompting or reminding a student to take his meds;
  2. Handing a pre-filled, labeled medication holder, labeled unit dose container, or original marked, labeled container from the pharmacy to the student;
  3. Opening the lid of a container for a student;
  4. Assisting with the removal of the med from a container or package;
  5. Guiding the student’s hand to self-administer; and
  6. Holding and assisting the patient in drinking fluid to assist in swallowing oral meds.

 

 

School District Example: Administration of Medication

Medication Procedures

A. School Administered Medications (Prescription, Non-Prescription, or “Over-the-Counter”)

  1. All prescriptions or non-prescription medications shall be

a. Accompanied by written parental consent.

b. Accompanied by current written orders (directions and prescription) from the student’s licensed medical provider, dentist, nurse practitioner, or licensed medical provider’s assistant. Orders shall indicate the student’s name, medication, dose, route, time of administration, medication’s purpose, a statement that the medication is necessary during school hours, and any possible side effects and procedures to follow if a severe reaction occurs.

c. Sent in a pharmacy or manufacturer’s labeled container. The pharmacy label shall include the student’s name, name of medication, dose, time, and route. Students on more than one medication (or requiring different dosages of the same medication) shall provide separate pharmacy or manufacturer labeled containers for each medication.

d. Kept in a locked cabinet or drawer with the information described in 1.a. and 1.b. above.

e. Recorded on the Medication Record Form by the designated school employee who administers the medication.

f. Administered by a principal-designated school employee who shall receive annual training by a nurse in medication protocol and precautions.

  1. For parents who request that their elementary students carry their own Epipens, insulin, or asthma inhalers, the licensed medical provider’s order must include a statement that the student is capable of carrying and self-administering his/her own medications and that it is medically necessary for them to keep the medication with him/her at all times.(Authorization to Posess Form)
  1. Written orders must be presented to the school office at the beginning of each school year and as medication is prescribed or changed. Requests for changes in dosage, time, or route for any medication shall be accompanied by a written order (see 1.b. above) and new appropriately labeled containers with updated information. Requests to discontinue medication shall be accompanied by a written parent request and written licensed medical provider’s order. A copy of these instructions shall be kept on file with the designated school employee.
  1. Students with diabetes, seizure disorders, or severe allergic disorders that require emergency medication shall have written instructions from their health care provider, written instructions from parents, and names and telephone numbers of emergency contact persons. A nurse shall review the procedure for administering emergency medications with a school administrator and school personnel, as appropriate.
  1. All medication that is to be given at school must be furnished by the parent or guardian and delivered to the school by a responsible adult. Unused medication must be picked up by a responsible adult within two weeks following the last dose administered. Medication remaining at the school after this time should be destroyed according to the direction of the nurse.

Self-Administered Medications or Other Substances

  1. Secondary students may retain and self-administer medications subject to the following:

a. Medication, prescription or non-prescription, shall be taken only as directed by prescription or manufacturer’s directions; and

b. Medication, prescription or non-prescription, shall not be sold, shared, or otherwise given to others.

  1. A responsible adult must transport syringes (insulin pens excepted) to and from school, and they must be kept in a locked cabinet or drawer in the

Other Information

  1. The school district may withdraw authorization for self-administration of medication at any time, in accordance with school district policy with parental notice.
  1. Violation of the district’s medication policy may be regarded as substance abuse and could result in disciplinary action pursuant to the school district’s policies and procedures regarding substance abuse.
  1. Forms and sample letters to assist with the administration of medication and communication with parents about this memorandum are available from the school district’s administration.

Forms and Resources

References

American Nurses Association. (1994). Registered professional nurses & unlicensed assistive personnel (Position Statement). Washington DC: Author.

National Association of School Nurses (2002). Using Assistive Personnel in School Health Services Programs (Position Statement). Scarborough, ME: Author.

Haynie, Marilyn (1997) Students and Youth Assisted by Medical Technology in Educational Settings-Guidelines for Care. A Manual for: Educators, School Nurses, and Parents

American Academy of Pediatrics (1997). Policy Statement. Guidelines for the administration of medication in school (RE9328). Pediatrics, 92(3), 499-500. Retrieved on May 13, 2003 from http://www.aap.org/policy/04524.html

Awbrey, L.M. & Juarez, S.M. (2003). Developing a nursing protocol for over-the counter medications in high school. Journal of School Nursing, 19(1), 12-15.

Dockrell, T.R. & Leever, J.S. (2000). An overview of herbal medications with implications for the school nurse. Journal of School Nursing, 16(3), 53-58.

McCarthy, A.M., Kelly, M.W., & Reed, D. (2000). Medication administration practices of school nurses. Journal of School Health, 70(9), 371-376.

National Association of School Nurses (1999). Position Statement: The use of asthma inhalers in the school setting. Available at: http://www.nasn.org/positions/asthma.htm

National Association of School Nurses (2000). Position Statement: Epinephrine use in life-threatening emergencies. Available at: http://www.nasn.org/positions/Epinephrine.htm

National Association of School Nurses (2000). Position Statement: Out-of-school education: Field trips and camps. Available at: http://www.nasn.org/positions/outofschool.htm

National Association of School Nurses (2001). Position Statement. Alternative medicine use in the school setting. Available at http://www.nasn.org/positions/ altermedi.htm

National Association of School Nurses (2001). Position Statement: Research medications in the school

>>Healthcare Procedures<<

NASN Position Statement
"Medication Administration in the Schools"

SUMMARY   

It is the position of the National Association of School Nurses (NASN) that the registered professional school nurse (hereinafter referred to as school nurse) be responsible for medication administration in the school setting, leading the development of written medication administration policies and procedures that focus on safe and efficient medication administration at school. Well-written policies and procedures will enable schools to fulfill their obligations to provide health-related services to all children, including those with special healthcare needs under the Individuals with Disabilities Education Improvement Act (2004) and Section 504 of the Rehabilitation Act (1973) as amended through the Americans with Disabilities Amendment Act [ADAA] in 2008.

Policies and procedures should address (Ryan, Katsiyannis, Losinski, Reid, & Ellis, 2013; U.S. Food and Drug Administration [FDA], 2013):

  • delegation (when permissible by state law), training and supervision of unlicensed assistive personnel (UAP);
  • student confidentiality;
  • medication orders;
  • medication doses that exceed manufacturer's guidelines;
  • proper labeling, storage, disposal, and transportation of medication to and from school;
  • documentation of medication administration;
  • rescue and emergency medications;
  • off-label medications and investigational drugs;
  • prescription and over-the-counter (OTC) medications;
  • complementary and alternative medications; and
  • psychotropic medications and controlled substances.

The administration of medication by non-nursing school staff, when allowed, should be addressed (Ryan et al., 2013). These policies and procedures shall be consistent with federal and state laws including state nurse practice acts, rules, regulations, and any other laws that may apply, as well as standards and established safe, evidence-based information (Ryan et al., 2013; Bobo, 2014).

BACKGROUND

Medication administration to students is one of the most common health‐related activities performed in school. Historically, administering medication within the school setting has been a school nurse responsibility. However, as many districts and schools struggle financially, it is not uncommon for students to receive medication from non-nursing school employees who have had no medical training. This trend has caused an alarming increase in the number of medication errors made by UAP (Institute for Safe Medication Practices [ISMP], 2012). It is especially important that evidence-based medication policies and procedures be in place in those schools where a registered nurse is not present every day.

It is estimated that up to 27% of children have chronic health conditions (Van Cleave, Gortmaker, & Perrin, 2010). As more students with chronic conditions enter school systems each year, awareness of the factors which can promote and support their academic success increases. This includes the need for medications which enhance students’ overall health or stabilize their chronic health conditions.

Medications, when administered and used appropriately, can improve student health but may be harmful if administered incorrectly. Errors in medication administration are the most common medical errors (Cloete, 2015). Examples of medication errors include administering medication to the wrong person, giving the wrong dose, or not giving a dose as scheduled. For the safety of students, it is critical that evidence-based policies and procedures exist regarding medication administration. School nurses have the health expertise needed to develop, promote, and implement policies that are evidence-based; reduce errors; and increase the proper use and storage of medications in school settings (American Academy of Pediatrics [AAP], 2016; ISMP, 2012).

RATIONALE

To reduce errors and increase safety, written policies and procedures for schools should include documentation from a licensed provider for the medication; proper labeling of medications brought to school; training of other staff involved in medication administration; storage of medication; process for administering medication (including proper identification of student and medication); documentation of medication administration, errors, reactions or side effects of medication; and proper disposal of medications (National Coordinating Council for Medication Error Reporting and Prevention [NCCMERP], 2007; 2015; FDA, 2013; Ryan et al., 2013). The principles of leadership, care coordination, quality improvement, public health/community, and standards of practice guide the practice of school nurses, including their role in medication administration (NASN, 2016).

Leadership
As the expert healthcare provider in the educational setting, the school nurse is critical to the safe and effective administration of medication to students. The school nurse should lead in the development, implementation, and evaluation of medication administration policies and procedures at the school or district level. Training and supervision of UAPs who administer medications should be done by the school nurse, and consideration of safety and school nurse workload is essential. There is a decrease in errors when a culture of safety exists that includes proper oversight and written policies in place (U.S. Department of Health and Human Services [USDHHS], 2011).

School medication policies and procedures must be in accordance with all applicable laws, including nurse practice acts (NPA). For example, delegation and training are often specifically noted in states’ NPAs. Registered nurses possess the knowledge about how to comply with NPAs and issues such as over-the-counter medications, off-label usage, and alternative medications in a safe, evidence-based manner (American Nurses Association [ANA], 2012; AAP, 2016).

Care Coordination
Medication administration is often part of a larger plan for the care and management of acute and chronic health conditions. There must be communication and collaboration between parents, providers, and schools regarding each student’s medication that describes what is to be given, the purpose, frequency, and side effects of the medication (NCCMERP, 2007; American Academy of Pediatrics, American Public Health Association, & National Resource Center for Health and Safety in Child Care and Early Education, 2011). School nurses are the health professionals in the school who coordinate care for the student, including medication administration.

Quality Improvement
The necessity for student use of medication at school has risen over the last two decades because many students who attend school have complex and chronic medical problems (ISMP, 2012). Research has shown that there are fewer medication errors in schools when medications are provided by a school nurse and when evidence-based policies are routinely followed (ISMP, 2012). Medication policies and procedures should include provisions for evaluation of medication practices and policies, including reviews of documentation and occasional audits, to identify possible concerns and adjust practice or policy as needed (USDHHS, 2011).

Community/Public Health
School nurses understand the unique needs and environments of their populations, which should be addressed in schools’ medication policies and guidelines (NCCMERP, 2015). School nurses can identify and address issues that may affect management of acute and chronic health conditions, such as environmental factors and socio-economic challenges, including obstacles to obtaining medications and delivery of medication to the school (Blaakman, Cohen, Fagnano, & Halterman, 2014). Evidence indicates that school nurses can provide culturally appropriate, sensitive information for students and families regarding management of health issues, including proper use of medications (McNaughton, Cowell & Fogg, 2014).

CONCLUSION

The school nurse should lead the development of school district policies and procedures relating to medication administration in the school setting and, where delegation of medication is permitted, the school nurse should be responsible for the delegation, training and supervision of UAP. The school nurse is the professional with the clinical knowledge and understanding of the complex issues surrounding the safe administration of medication and the responsibility to protect the health and safety of students (AAP, 2016; ANA, 2012). As the health leader in the school setting, the school nurse promotes current evidence-based practices so students requiring medication during the school day can safely have their needs met and remain in school ready to learn (Maughan, 2016)