Medication Administration in the School Setting Guidelines

Document Sample
Medication Administration in the School Setting Guidelines Powered By Docstoc
					Medication Administration in the School
          Setting: Guidelines

  Colorado Department of Education




                revised
               May 2010




                                 Page 0 of 42
The Colorado Department of Education would like to
acknowledge and thank the following people for their
    contributions in developing these guidelines



Kathleen A. Patrick, RN, MA, NCSN – Colorado Department of Education

Judith F. Harrigan, RN, MSN, retired – Colorado Department of Education

         Christine Perreault, BSN, RN – The Children’s Hospital

          Linda Satkowiak, ND, RN – Qualistar Early Learning

    Catherine Hicks, RN, MHS – Colorado Department of Regulatory
                             Agencies

           Katie Bernard, RN, BSN – Aurora Public Schools

         Kris Evenson, RN, MS, NCSN – Poudre School District

           Pamela Brunner Nii, RN – The Children’s Hospital

       Sandy Peterson, MSN, ANP, RN-C-Cherry Creek Schools




                                                            Page 1 of 42
MEDICATION ADMINISTRATION IN THE
SCHOOLS - GUIDELINES
                                  § 1.OVERVIEW
                                  A significant number of school                          acute, but temporary, medical
                                  children have health problems that                      needs that require medicine
SECTIONS:                         require the administration of                           during the school day, such as
                                  medication during the school day.                       an antibiotic for an infection
OVERVIEW                      2   That number has been growing                            conditions that might require
LEGAL CONSIDERATIONS 3            rapidly. For example, the number                        emergency medication, such as
                                  of American children being treated                      Epi-pen® for a bee sting or food
ROLE OF SCHOOL NURSE 3
                                  with psychiatric drugs has grown                        allergy.
   Delegation            pg 15   sharply in the last 15 years, even
   Record Keeping           18
                                  tripling from 1987 to 1996 and                      The National Association of
                                  shows no signs of slowing.1                         School Nurses states that the
   Medication Errors       20    The issue of medication                             school nurse has the educational
   Self Administration     22    administration within the school                    background, knowledge, and
                                  setting is critical because                         licensure that provide the unique
   Over-the-Counter              medications keep children in                        qualifications to direct the
    Medications             24    school without interruption of the                  administration of medications in
                                  learning process so they can                        the school setting. Its position
   Homeopathic & Herbal
                                  learn. It has become a more                         statement recommends that
    Remedies                26    complex issue due to a variety of                   “school districts develop policies
   Field Trips             29
                                  factors, such as federal and state                  and procedures to address
                                  disability law, new pharmaceutical                  medication administration in
   Experimental                  and medical technologies,                           accordance with federal and state
    Medications             32    evolving mental and medical                         laws and guidelines”.2 If a child
                                  health practices, fewer full-time                   needs specified medication during
   Off-Label Use           32
                                  school nurses, and increasing                       the course of the school day to
   Psychotropic                  numbers of children with complex                    attend school and benefit from the
                                  as well as simple health needs in                   educational program, it is in the
    Medications             33
                                  schools. Children who require                       school's interest to make this
SCHOOL NURSE                      medications in order to fully                       accommodation.3
& COLLEAGUES                  4
                                  benefit from a free appropriate
                                  public education (FAPE) are
RESOURCES                     5   protected by federal and state
   Colorado              pg 38   disability laws. There are a
                                  number of reasons why students
   National                 39
                                  might require medications in
REFERENCES                    6   schools, including:
                                     chronic conditions requiring
                                     medication in order to benefit
                                     from classroom instruction                       2
                                                                                        National Association of School Nurses.
                                                                                      (2003). Position statement: Medication
                                                                                      administration in the school setting.
                                                                                      http://www.nasn.org/positions/medication.htmv.
                                  1                                                   3
                                   Zito, J.M., et al. (2003). Psychotropic Practice     Schwab, N.C. and Gelfman, M.H.B., (2001).
                                  Patterns for Youth: A 10-Year Perspective.          Legal Issues in School Health, Sun River
                                  Archives of Pediatrics and Adolescent               Press, North Branch, MN: Sunrise River Press,
                                  Medicine, 157(1), 17-25.                            205.




                                                                                                                   Page 2 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                     § 2. LEGAL CONSIDERATIONS
                     To protect the school and staff                     return demonstration by the
                     from liability and to insure student                delegatee in the routes of
                     safety, schools must provide for                    medication administration
                     the safe administration of                          documentation of medication(s)
                     medication to students under strict                 given
                     guidelines. In settings where the                   documentation of medication(s)
                     schools registered, professional                    not given or taken by a student,
                     nurse is not on campus at all                       and
                     times, the registered nurse must                    planned evaluation and
                     delegate the task of medication                     supervision to assure the
                     administration to a school staff                    delegatee’s continued
                     member who has been trained to                      competency
 School nurses       administer medications. If the                   Districts are best protected from
 have a legitimate   school nurse is unable to                        liability when policies and
 educational         administer the medication(s),                    procedures are established
 interest in all     designated school staff members                  collaboratively with input from
 students who        must be trained in medication                    school nursing personnel, district
                     administration and the school                    administrators, and parents.
 take any
                     nurse must delegate the                          Parents should be advised
 medications,        responsibility of administering
 whether those                                                        annually of the district’s
                     medications to those trained staff               medication policies and
 medications are     members. That state-approved                     procedures.
 administered        training should cover the basic
 before or during    tenets of medication                             Safe medication administration
 school.             administration, as outlined in                   requires a process that includes
                     Guide for Medication                             the observation and reporting to
                     Administration: An Instructional                 the school nurse or her delegatee
                     Program for Training Unlicensed                  of a student’s refusal to take
                     Persons to Give                                  medications, side effects, adverse
                     Medications in Out-of-Home                       reactions, and unusual symptoms.
                     Childcare, School, and Camp                      The school nurse helps staff
                     Settings4 and must include:                      identify potentially dangerous drug
                       development of a school district               adverse reactions and reviews
                       policy regarding medication                    health information for problems,
                       administration                                 including side effects of
                       written authorization from the                 medication that may interfere with
                       student’s parent/guardian                      learning.
                       written authorization from the
                       prescribing health care provider

                     4
                       Guide for medication administration: an
                     instructional program for training unlicensed
                     personnel to give medications in out-of-home
                     child care, school and camp settings (2008).
                     http://www.qualistar.org/professionals/mat.php




                                                                                             Page 3 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                                     LEGAL CONSIDERATIONS (continued)
                                     Special issues to consider include:    day. It is important to check with
                                      psychotropic (brain) medications      the parent and/or student about
                                      self-administration of                medications that are taken at
  Being trained to                    medications                           home and to determine whether
                                      administration of medications all     doses of medication have been
  give medication                                                           administered or forgotten at home.
                                      school-sponsored events
  is not the critical                 including out-of-school activities
  issue -- The                        delegation of authority to            Policies regarding administration
                                      administer medications                and storage of medications should
  critical issue is
                                      over-the-counter (OTC) and            be clearly defined and designed to
  having time to                                                            protect:
                                      homeopathic remedies
  give it right and                                                           the student
  give the students                  Depending on the child and school        the person responsible for the
  the care they                      policy, medications may be               administration of medication, the
                                     administered by:                         person responsible for
  deserve.                             the school nurse or her                delegation of that responsibility
                                       delegatee                              the school
         Julia Lear                    a parent                               the local school district,
                                       a person in the act of                 regardless of whether the
                                       emergency care                         medication is administered at
                                       the child who has been                 school during the school day,
                                       approved to self-administer            after school at school sponsored
                                     School nurses have a legitimate          activities, or at off site activities.
                                     educational interest in all students     These policies and procedures
                                     who take any medications,                should be clearly and regularly
                                     whether those medications are            communicated to students, their
                                     administered before, during or           parents, school staff, and
                                     after school.                            community health care
                                     Medications taken or not taken           providers.
                                     before coming to school may
                                     affect a child during the school




Source: Lear, J.G. (2002).
Improving Safety and Quality in
Medication Management in Schools.    NOTE: The remainder of the Legal Considerations section discusses
Center for Health and Health Care    specific issues related to medication administration from a broad legal
in Schools.                          perspective. These issues will be discussed in greater depth from a
http://www.healthinschools.org/com
                                     practice perspective in Section 3: Role of the School Nurse.
m/Medmgmt/sld001.htm.




                                                                                                     Page 4 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                       LEGAL CONSIDERATIONS (continued)
                       ADMINISTRATION OF MEDICATION

                       Administering medications to             nursing judgment when
                       children in schools and                  administering medications.
                       childcare settings without a             Administering medications without
                       nursing license is in violation          a nursing license is in violation of
A prescription or                                               12-38-103 (9) and (10) of the
over-the counter       of the Colorado Nurse
                                                                Colorado Nurse Practice Act. The
medication is one      Practice Act.                            “delegatory clause” of the Nurse
that has been                                                   Practice Act permits nurses to
approved by the        If a student requires medication in      delegate nursing tasks of a routine
Federal Drug           order to access a free appropriate       and repetitive nature that do not
                       public education (FAPE) under            require nursing judgment to
Administration
                       federal and state disability laws,       unlicensed persons who have
(FDA) and              then the administration of such
provides                                                        been trained to administer
                       medication is an appropriate             medications. 6 The rules and
evidence- based        “related” or support service as          regulations implementing the law
information about      defined be federal law. The              allow for delegation of the
its purpose,           service should be incorporated           administration of medication in
dosage, adverse        into the student’s IEP or section        schools and child care settings
reactions, side        504 accommodation plan. State            and are found in Chapter XIII.7
effects, etc.          law and regulation and local
Homeopathic,           district policies define how
holistic, or natural   medication should be
remedies are           administered both for the
generally not          student for whom this is a related
                       service and for students whose
approved by the
                       need for medication administration
FDA.                   may be for temporary or
                       emergency conditions.

                       The Colorado Medical Practice
                       Act governs the administration of
                       medication.5 Licensed
                       professional and practical nurses
                       are allowed to administer
                       medications to “their patients”
                       through a delegated medical
                       function. Each carries
                       independent responsibility through
                       licensure to use appropriate
                                                                6
                                                                 §12-38-101 C.R.S. Colorado Nurse Practice
                                                                Act.
                       5
                        § 12-36-106(1), CRS. Colorado Medical
                       Practice Act.




                                                                                            Page 5 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              LEGAL CONSIDERATIONS (continued)
              ADMINISTRATION OF MEDICATION

              While not expressly stated in law or regulation, many Colorado
              schools use some variation of the following policy. 8

              A school may administer                              Name of drug
              medication to a child only if a                      Dosage
              parent or guardian has specifically                  Purpose of the medication
              requested such action and there is                   Time of day medication is
              a reason to administer the                           to be given
              medication when the child is at                      Anticipated number of days it
              school. A written order from an                      needs to be given in school
              individual who is licensed to                        Possible side effects
              prescribe medications must be on
              file in order to administer                       3. The parent/guardian provides
              medications. Medication may be                    written permission to the school to
              given legally only by trained                     administer a prescription or over-
              school personnel that have                        the-counter medication.
              participated in the required
              Medication Administration                         4. School personnel keep an
              Training and to whom a registered                 individual record of any
              nurse has delegated the task of                   medications administered by
              medication administration.                        school personnel.
              Neither the school nurse nor her
              designee is permitted to                          5. Medication is stored in a clean,
              administer medication unless:                     locked cabinet or container.
              1. The medication is in the original
              properly labeled container.                       Additionally, school districts may
              If it is a prescription medicine, the             want to consider requiring parents
              student’s name, name of the drug,                 to sign a release from
                                                                responsibility pertaining to side
              dosage, time for administering,
                                                                effects or other medical
              and name of health care provider                  consequences that may be related
              and current date is printed on the                to the medication(s).
              container.

              2. Written orders from the
              student's health care provider are
              on file in the school stating:
                Student’s name

              8
                Administering Medicines to Students (Revised Sample Policy): Sample Policy JLCD, Rev May
              2001. http://www.cde.state.co.us/cdesped/download/pdf/nurAdminMed2StuRSP.pdf, Sample
              Regulation JLCD-R, Administering Medicines to Students (Revised Sample Regulation):
              http://www.cde.state.co.us/cdesped/download/pdf/nurAdmMeds2StuRSR.pdf




                                                                                             Page 6 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                                 LEGAL CONSIDERATIONS (continued)
                                 DISPENSING OF MEDICATION

                                 The process of administering                    administer and dispense in the
                                 medication does not include                     same policy.10 School nurses
   Five Rights of
                                 dispensing. Only pharmacists,                   should read their district policies
    Medication                   advanced practice nurses,                       carefully, especially with regard to
  Administration:                physicians, and practitioners                   medications on field trips. The
      Right Patient              licensed to do so may dispense                  preparation of individual doses of
                                 drugs. Nurses, unless licensed as               medications for field trips is not
      Right Route
                                 advanced practice nurses with                   considered dispensing according
      Right Dose                 prescriptive authority, may only                to the Colorado Pharmacy Board if
      Right Time                 administer medications and,                     the parent has provided the
      Right                      therefore may only delegate the                 medication to the school.
      Medication                 administration of medications.9                 Generally preparation of an
                                                                                 individual dose can be considered
                                 While state law prohibits
                                                                                 part of the administration process.
                                 dispensing of medications by
                                                                                 However, if multiple doses are
                                 nurses, many Colorado school
                                                                                 required, it is recommended that
                                 district policies on administration
                                                                                 they be individually packaged by a
                                 of medication in school refer to
                                                                                 pharmacy or sent in their original
                                                                                 containers filled with the number
                                                                                 of doses required for the field trip.




 Source: The Five Rights of
 Assisting with Medications,
 Jefferson County Public
 Schools Health Services,
 http://jeffcoweb.jeffco.k12.c
 o.us/edservices/health/rxtr
 aining/5rights.html.;
 Colorado Board of Nursing.
 The Five Rights Of
 Medication Administration.
 http://www.dora.state.co.us
 /nursing/newsandhottopics/
 newsandhottopics.htm
 #5RIGHTS and Colorado
 Board of Nursing. The five
 rights of medication
 administration.


                                                                                 10
                                                                                   Colorado Association of School Boards. First
                                                                                 Aid and Emergency Medical Care (Revised
                                                                                 Sample Policy).
                                 9
                                     §12-22-121 Colorado Pharmacy Practice Act




                                                                                                               Page 7 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              LEGAL CONSIDERATIONS (continued)



              MEDICATION PROTOCOLS                               SELF-MEDICATION

              It is recommended that districts                   In 2005, Colorado initially passed
              develop policies if they wish to,                  the Asthma, food allergy, and
              allow administering analgesics for                 anaphylaxis health management –
              headaches or pain, topical                         self administered medication law12
              preparations, throat lozenges, or                  which allows students to self carry
              remedies for stomach upset only                    emergency epinephrine and
              when a parent or guardian and an                   prescription inhalers under certain
              authorized prescriber have given                   circumstances.
              written authorization for their                    Currently, Colorado does not have
              use.11                                             regulations that address student
                                                                 self-medication with insulin, and
                                                                 other prescribed medications, or
                                                                 over-the-counter medications.
                                                                 Individual school districts may
                                                                 have very specific policies on self-
                                                                 administration of medications. It is
                                                                 recommended that designated
              EMERGENCY MEDICATIONS                              staff members be instructed in the
                                                                 care of students who may
              Even in emergency situations                       experience a need for emergency
              such as anaphylaxis,                               medications such as epinephrine
              hypoglycemia, or respiratory                       or inhalers even if the student has
              distress school staff should not                   permission to carry and self-
              give any medications at any time,                  administer the medication. It may
              unless the medication has been                     be necessary that the student
              ordered for that particular child.                 experiencing such an emergency
                                                                 will need assistance from a trained
                                                                 staff member.
                                                                 More specific guidelines for self-
                                                                 medication are included later in
                                                                 this paper.


              11
                 Jefferson County Public Schools Health
              Services (n.d.). Five rights of assisting with
              medications
              http://jeffcoweb.jeffco.k12.co.us/edservices/hea
              lth/rxtraining/5rights.html. and Colorado Board
                                                                 12
              of Nursing. The five rights of medication            § 22-1-119.5. C.R.S. Education Law, General
              administration.                                    Provisions




                                                                                              Page 8 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              LEGAL CONSIDERATIONS (continued)
              MEDICATION ADMINISTRATION AND IMMUNITY FROM CIVIL
              LIABILITY

              Colorado law provides immunity to
              any school employee who
              administers any medication to a
              student in accordance with written
              instructions from a parent or legal
              guardian if there is an adverse
              drug reaction suffered by the
              student as a result of dispensing
              such drug.13




              13
                 §22-1-119 C.R.S. Education Law, General
              Provisions




                                                           Page 9 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                        LEGAL CONSIDERATIONS (continued)
                        STORING MEDICATIONS

                        All medications should be stored     medications such as epinephrine,
                        in a locked drawer used              glucagon, etc. are stored and who
                        exclusively for medications.         is responsible for administering it.
                        Cabinets should not contain glass    District policy should specify that
                        doors and should be anchored         emergency medications should be
                        securely to a solid surface.         accessible to staff or students who
                        Medication requiring refrigeration   might need them, but be
                        should be stored in a locked         inaccessible to others.
                        refrigerator or in an impervious
                        secondary container in the           Needles and syringes should be
                        refrigerator. Medications should     disposed of in a manner
Although FDA            not be stored in individual          consistent with the following
regulations apply       classrooms unless all of the above   guidelines:
                        standards can be met & the             Needles should not be recapped
only to health          individuals responsible for            and should not be purposely
facilities and not to   administration have been properly      bent or broken.
schools, special        trained. All medication should be      Disposable syringes and
                        stored in the original pharmacy or     needles (and other sharp items)
care is needed for
                        manufacturer labeled container.        should be placed in approved
controlled              Access to stored medication and        red sharps containers and
substances such         medication cabinet keys must be        labeled “Biohazard.”
as Ritalin              limited to school personnel            Arrangements should be made
                        authorized to administer               with custodial staff or other
                        medications. Expiration dates          agents to dispose of containers
                        should be checked and                  according to established
                        medications returned to parents or     procedures for regulated
                        properly disposed of upon              medical waste at periodic
                        expiration.                            intervals.

                        It should be made clear in
                        advance where emergency




                                                                                   Page 10 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              LEGAL CONSIDERATIONS (continued)
              CONTROLLED SUBSTANCES

              Although Federal Drug                         Additionally, the FDA
              Enforcement Administration                    recommends that:
              regulations apply only to health                Schools consider prohibiting
              facilities and not to schools,                  students from carrying controlled
              controlled medications should:                  substances to and from school
                Be inaccessible to children                   and require that a parent,
                Be stored in the original                     guardian, or other responsible
                container in a controlled area                person deliver and remove
                separated from food, cleaning                 these medications from school
                compounds, and other toxic                    One person (preferably the
                substances                                    school nurse or a delegate who
                Be safely secured                             is knowledgeable about the risks
                Be counted when received in the               inherent with controlled
                health office and at least weekly             substances) maintain primary
                thereafter and the count                      control of the medication supply
                documented in an inventory log                Schools consider not permitting
                according to district protocols. If           a student to self-administer
                the count is discrepant with                  controlled medications outside
                records, theft should be                      the presence of school staff so
                suspected and local law                       there is verification that the
                enforcement authorities should                medication has been consumed
                be notified.                                  and an appropriate pill count can
                Require special attention in the              be kept
                school district’s policies in terms           The drug supply be secured in a
                of storage, and documentation                 locked drawer, room or cabinet;
                of administration                             non-duplicative keys to the
                Be disposed of either by                      locked storage area, limited; and
                returning unused quantities to a              an inventory and accountability
                responsible family member or in               systems for the keys be
                accordance with the EPA and                   maintained15
                CDPHE.14 It is no longer
                recommended to flush even
                small quantities of
                medications down the drain.



              14
               Environmental Protection Agency –
                                                            15
              www.epa.gov , Colorado Department of Public     §12-22-318 C.R.S. Pharmacy Practice Act.
              Health and Environment -                      See also National Association of School Nurses
              http://www.cdphe.state.co.us/hm/hhw/howto/m   (2001). Position statement: Controlled
              edications.htm                                substances in the school setting.
                                                            http://www.nasn.org/position/controlled.htm.




                                                                                        Page 11 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              LEGAL CONSIDERATIONS (continued)
              TRANSPORTING MEDICATIONS
              Medications should be transported
              to and from school by a
              responsible adult who delivers the
              medications to a designated
              individual in the school.
              Medications should be delivered in
              original pharmacy or
              manufacturer-labeled containers.
              Students who have been
              approved to carry and self
              administer their own medications
              may transport them to and from
              school. Controlled substances
              should not be transported by
              students.




                                                   Page 12 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              § 3. ROLE OF THE SCHOOL NURSE
              The responsibility of the school’s     establishing procedures for
              professional registered nurse is to    training, on-going supervision,
              assure that procedures are in          and evaluation of
              place for the safe administration of   paraprofessionals or
              all prescription and over-the-         unlicensed assistive personnel
              counter medications, including         for any delegation of
              proper storage, administration,        administration of medications
              documentation, and follow-             working with school staff to
              up/evaluation. The nurse and all       clarify language referring to
              staff involved in medication           medication administration in all
              administration must adhere to          individualized education plans
              confidentiality standards to protect   (IEPs, 504 plans), individualized
              staff and students. Appropriate        health care plans (IHPs), and/or
              activities include:                    emergency health care plans
                reviewing and understanding          training all school staff to
                state laws, regulations, and rules   recognize signs and symptoms
                related to medication                of medication adverse reactions
                administration, delegation, and      and/or problems, such as
                on-going supervision                 overdoses, skipped dosage(s),
                reviewing existing local school      etc. and necessary action steps
                district policies, procedures, and   reviewing ability of all children
                forms related to medication          who are allowed to self-medicate
                suggesting revisions as              and developing procedures to
                necessary to local school district   communicate with child, parent,
                policies, procedures, and forms      and child’s health care provider
                related to medication, to comply     if student is exhibiting difficulty in
                with federal and state mandates,     self administration
                nursing standards and current        withdrawing permission to self-
                best practices                       administer from students who
                reviewing pharmacology and           are not compliant with self-
                dosage of all medications to be      administration policies
                administered                         communicating medication
                ensuring that all medication         administration policies and
                administration is accompanied        procedures on a regular basis to
                by proper parental permission        students, parents, and school
                and prescriber orders in             staff
                accordance with district policies    observing and evaluating
                establishing and ensuring            student health status and
                documentation and quality            response to medication
                control systems for storage and      assuring that school
                administration of medications        transportation and disaster plans
                both on site and at off-site         consider medication issues.
                school-sponsored events




                                                                           Page 13 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                                   ROLE OF THE SCHOOL NURSE (continued)
                                   REVIEWING THE MEDICATION ORDER

                                   The school nurse needs to ensure         prescriber within 24 hours. The
                                   that any order for a prescription        registered school nurse is the
                                   medicine is properly authorized as       only person authorized to accept
                                   described above. Additional              verbal orders and the initial dose
                                   recommendations include:                 should be administered and
                                                                            documented by the RN.
                                        Establishment of procedures for
                                        reauthorization of the permission   inclusion of medications,
     TIP: Handling and                  and consent forms if medication     including pertinent
     Administration of                  is to be given over an extended     administration information, in the
     Medication                         time including                      written plan (IEP, 504
     Jefferson County                                                       accommodation plan, or
     Public Schools has                 a new medication authorization
     a checklist on
                                                                            individualized health care plan);
                                        form signed by the parent and
     procedures for                     health care provider, along with    inclusion of special limitations or
     medication                         a change in the prescription        orders to delegation instructions
     administration.                    label for any changes in the        (e.g. mixing instructions,
                                        original prescription               administration routes,
                                                                            instructions to administer the
                                        a signed written order should
                                                                            medication before/after eating,
                                        follow a verbal order from the
                                                                            etc.)
                                   ************************************************************
                                   Who is a Licensed               Who is not a Licensed
                                   Authorized Prescribing          Authorized Prescribing
                                                 16
                                   Practitioner?                   Practitioner?
                                         Physician                            Licensed Practical or
                                         Advanced practice registered         Registered Nurse
                                         nurse (NP) with prescriptive         Medical assistant
                                         authority                            Nutritionist
                                         Physician Assistant (PA) who         Psychologist
                                         has direction from a physician       Naturopathic physician (ND)
                                         or written protocol                  Chiropractor
                                         Dentist
                                         Podiatrist
                                         Osteopath
Source: Jefferson County
Public Schools Health                    Psychiatrist
Services (n.d.) Handling and
administration of medication.
http://jeffcoweb.jeffco.k12.co.u
s/edservices/health/rxtraining/
overview.html.
                                   16
                                      §12-38-111.6 C.R.S. Colorado Nurse
                                   Practice Act




                                                                                                Page 14 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                               ROLE OF THE SCHOOL NURSE (continued)
                               DELEGATION

 Best Practice –               Delegation of medications is
 adhering to the               allowed in Colorado schools in an
 Guide for                     attempt to achieve balance
                               between safety standards and
 Medication                    reasonableness, given limited
 Administration:               resources in schools, rights of
 An Instructional              students, and the assumption that
 Program for                   students constitute a healthy
 Training                      population.17 A professional nurse
 Unlicensed                    employed or contracted by a
 Personnel to                  school may delegate the
 give                          administration of oral, topical
 Medications in                including eye and ear drops, and
 Out-of-home                   inhaled medications to a specific
 Child Care,                   delegate(s) for the population of a
                               school, within a specific time
 School and                    frame not to exceed one school
 Camp Settings                 year.
 in delegating,
 supervising,
 monitoring, and               Delegation Of Responsibility To Administer Medication
 documenting all
 facets in the                 The Delegatory Clause of the                   the medication
 administration                Nurse Practice Act authorizes                   administration fits the
 of medications                unlicensed personnel to                         criteria of the Colorado
 to students.                  administer medications under the                Nurse Practice Act
                               delegation and on-going                        the unlicensed person
                               supervision of the school’s                     has completed a
                               registered nurse                                medication course
                                 Annual delegation is required                 training such as the
                                 Delegation to administer                      state approved
                                 medications by the professional               medication course
                                 school nurse to an unlicensed
                                 person can only be done if:
 Source:Guide for
 medication administration:
 an instructional program
 for training unlicensed
 personnel to give
 medications in out-of-
 home child care, school
 and camp settings (2008).
                               17
 http://www.qualistar.org/pr     §12-38-132 CRS. Colorado Nurse Practice
 ofessionals/mat.php           Act




                                                                                         Page 15 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)
              Criteria for Delegation

              Tasks that are delegated by a        Unlicensed school personnel must
              registered nurse to unlicensed       complete a medication training
              personnel:                           course before delegation can be
                  Must be within the area of the   assigned.
                  RN’s responsibility
                  Must be within the knowledge,    A registered nurse may delegate
                  skills, and ability of the RN    nursing procedures or the
                  Must be of a routine and         administration of emergency
                  repetitive nature                medications given by injection,
                  Must be defined in specific      rectally, or other routes or on a
                  written protocols provided by    case-by-case basis for individual
                  the RN                           students to a specific delegatee(s)
                  Must not require delegatee to    who has completed appropriate
                  exercise nursing judgment or     training and is judged by the RN to
                  interventions that have not      be competent to perform the task.
                  been delegated and clearly
                  defined                          For criteria about delegation in
                                                   specific settings, refer to Section
                  Cannot be further delegated to
                                                   4. The School Nurse and Her
                  another unlicensed individual
                                                   Colleagues and the document,
                  Must be documented,              Guide to Delegation for Colorado
                  supervised, and periodically     School Nurses.18
                  evaluated by the RN




                                                   18
                                                     Guide to Delegation for Colorado School
                                                   Nurses
                                                   http://www.cde.state.co.us/cdesped/download/p
                                                   df/nurDelegation.pdf




                                                                              Page 16 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)
              The School Registered Nurse Must:
                   Observe and document
                   competency of the unlicensed
                   person(s) to administer
                   medication
                   Delegate to the unlicensed
                   person(s) the task of medication
                   administration, to include routine
                   medications only. Any
                   medications not covered in the
                   medication training, must be
                   delegated on a case-by-case
                   basis
                   Provide and document on-going
                   supervision and evaluation of
                   the delegatee in the
                   administration of medications
                   Perform on-site medication
                   audits
                   Establish methods of
                   communication with the
                   unlicensed person(s) so that
                   questions about medication side
                   effects, errors or adverse
                   reactions can be addressed in a
                   timely manner during all school-
                   sponsored activities
                   Document the delegation,
                   keeping a copy with the nurse’s
                   records. A copy of the record of
                   delegation should also be given
                   to the unlicensed person(s) for
                   their files.19
                   Delegation must be renewed
                   annually




              19
                §12-38-132 C.R.S. Colorado Nurse Practice
              Act and Regulations, 7.1.




                                                            Page 17 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                  ROLE OF THE SCHOOL NURSE (continued)
                  RECORD KEEPING
                  School health personnel should         It is recommended that
                  maintain accurate individualized       medication logs be retained in
                  daily records of medications           the district for at least three
                  administered, any special              years from date of log or
                  circumstances related to the           according to district archival
                  procedure, and the student’s           policy. A summary of individual
                  unusual reactions or responses. A      records (e.g., 9/15 – 5/1 - Ritalin
                  separate medication log must be        20 mg at lunch time) should be
                  kept for each student and for each     transcribed to a student’s
                  medication. This log becomes a         cumulative health record. Logs
                  permanent record and provides          should not be destroyed if
                  legal protection to those who          summary information has not
                  administer medications in schools.     been transferred to the
                    A picture of the student attached    cumulative health record
 See sample         to the medication log or the
 Medication Log     medication authorization form is    The log should contain:
 in Appendix        helpful in assuring that the         Student’s name;
                    proper student gets the proper       Name of the medication, dosage
                    medication.                          and route;
                    Student confidentiality must be      Time medication is to be given;
                    protected as outlined in the         Special instructions;
                    Family Educational Rights &          Name and initials of the
                    Privacy Act (FERPA)                  individuals giving the
                                                         medication.




                                                                             Page 18 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)
              PROCEDURE FOR ADMINISTRATION OF MEDICATION


              1. Identify the student.         5. Check to see that another
                                                  individual has not already
              2. Identify the medication          given the medication for that
                 •Note student’s name on          day and time
                 bottle
                 •Note and compare picture     6. Administer the medication to
                 (if available) to student        the student as directed
                 •Note date of medication on
                 bottle                        7. Initial and record time the
                 •Note name of medication         medication was given on
                 on bottle                        student’s medication record
                 •Note dosage of medication
                 on bottle                     8. Return medication to locked
                 •Note instructions               medication cupboard20
                 on bottle for giving the
                 medication
              1. Compare information
                 on medication
                 bottle with
                 medication record
                 information.
              2. Health care plan
                 should be attached
                 to medication record
                 or in student file.




                                               20
                                                 Administering Medicines to Students
                                               (Revised Sample Policy): Sample Policy JLCD,
                                               Rev May 2001.




                                                                          Page 19 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)
              MEDICATION INCIDENTS


              School policies and procedures          Schools should have polices to
              should include what an individual       address handling situations with
              must do if there is an “irregularity”   students who do not appear or
              involving medication. A medication      refuse to take ordered medication.
              error includes any failure to           It may be best to address these
              administer a medication as              situations on an individual basis
              prescribed for a particular student.    dependent upon what the
              Medication errors most often            medication is and how often the
              occur when an individual is             student forgets. If a medication is
              interrupted or distracted.              not administered, polices should
              Eliminating distractions and/or         address the extent to which school
              other responsibilities during           personnel will attempt to
              periods of concentrated                 administer the medication and
              medication administration can           parent notification procedures.
              increase safety and decrease the        Any medication “irregularity”
              potential for errors. Medication        should be documented on a
              errors may include:                     “medication incident report form”
                omitting a medication                 and reported to the school nurse
                administering a medication to         and parents, as well as the
                the wrong student                     prescribing practitioner and school
                administering an incorrect dose       administrator if deemed
                of medication                         appropriate by the school nurse.
                administering the wrong               School nursing personnel should
                medication to a student               review reports of medication
                administering a medication at         errors and take necessary steps to
                the wrong time                        avoid problems in the future.
                administering a medication by
                the wrong route




                                                                           Page 20 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                      ROLE OF THE SCHOOL NURSE (continued)
                        MEDICATION CHECKLIST

                         Are you sure the                     If student has a health care
                          medication (type, strength,           plan and brings in new
 *Do not change           dose) is correct? If you are          medication, is there any
 the original             not sure, the school nurse            conflict between the new
 status of a              should call the prescriber            prescription and the
 medication               and/or the pharmacy that              current standing orders?
                          filled the prescription
 without checking
                          before giving the dose.              Are there specific
 to determine                                                   emergency orders in the
 whether                 Are OTC (over-the-                    event that the child does
 crushing,                counter) medications still            not respond to a PRN
 sprinkling, etc.         current?                              medication?21
 would change
 the properties of       Is there parental
 the medication. If       authorization for all
 a child is unable        medication?
 to take a
 medication in its       Is the medication in
                          original bottle/ container?
 original form,
 consult with the        Is medication properly
 pharmacist or            labeled with student's
 prescriber to            name and dosage?
 decide
 appropriate             Does the medication have
 options.                 specific storage
                          requirements (such as
                          refrigeration) and are those
                          requirements being met?

                         Does the order specify the
                          route of medication?

                         Does the order provide
                          special instructions (such
                          as crushing, sprinkling of
                          medication*) or instructions
                                                         21
                          on when to give the                Wolfe, L.C., and Selekman, J. (2002).
                          medication (with food,         School nurses: What it was and what it is.
                                                         Pediatric Nursing. 28(4),:403-407.
                          etc)?                          http://www.medscape.com/viewarticle/442679_
                                                         print.




                                                                                   Page 21 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)
              SPECIAL CONCERNS
              There are a variety of scenarios
              involving medication                            These scenarios illustrate the
              administration that may arise in                importance of collaboration among
              the school setting. This section                the school nurse, other school
              includes a few of the most                      staff, students and parents
              common.

              Self-Administration
              Parents or health care providers
              may request that students be
              allowed to carry and self-
              administer their own medications.
              Individual school districts should
              have specific policies on self-
              administration of medications,
              especially in the case of
              emergency illness.22

              Some districts allow middle and/or
              high school students to carry and
              self-administer certain prescription
              or over-the-counter medications.
              Students must be informed that
              this is a privilege granted to them
              as an individual and be advised
              that medications must be kept on
              their person or in a school locker
              and must not be shared with
              peers.




              22
                Brener, N.D., Burstein, G.R., DuShaw, M.L.,
              Vernon, M.E., Wheeler, L., and Robinson, J.
              (September 2001).School health policies and
              programs study (SHPPS) 2000. Journal of
              School Health, U.S. Department of Health and
              Human Services Centers for Disease Control
              and Prevention, (71)7: 294-303.
              http://www.cdc.gov/nccdphp/dash/shpps/report
              _cards/pdf/colorado.pdf




                                                                                  Page 22 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)
              Self-Administration (con’t)

              Colorado state law does allow                Any student self-administering
              students to carry and self-                  medication inappropriately or
              administer medication to treat               outside the bounds of district
              the student’s asthma, food                   policy should be counseled and
              allergy, other severe allergies, or          the parent notified. Medications
              a related life-threatening                   should be confiscated and self
              condition if the student has an              administration privileges be
              approved treatment plan.23 The               revoked if a student shares
              school nurse should facilitate               medication with others. Parents
              discussion with the student,                 should be notified of any side
              family health care provider                  effects or the student’s refusal or
              and/or school staff and consider             failure to take the medication as
              that:                                        ordered.25
                  Student is self directed and
                  knowledgeable about their
                  medication
                  Severity of health condition
                  warrants carrying & self
                  administration
                  Student demonstrates ability
                  to self administer medication
                  properly
                  Student is judged to be
                  responsible and mature
                  enough to carry medication
                  or secure it in the school
                  locker
                  Written authorization is
                  obtained from the parent
                  Parental responsibility is
                  clarified and agreed upon
                  School nurse is able to
                  monitor the self
                  administration process.24

              23
               § 22-1-119.5. C.R.S. Education Law,
              General Provisions

              24                                           25
                 National Association of School Nurses         American Academy of Pediatrics (2003).
              (2005). Position statement: Asthma Rescue    Guidelines for Administering of Medications
              Inhalers in the School Setting               in School www.aap.org/policy/s010105.html.
              http://www.nasn.org/Default.aspx?tabid=202




                                                                                    Page 23 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                   ROLE OF THE SCHOOL NURSE (continued)
                   Over-the-Counter Medications
                   There are many products that
                   affect the health and well-being of     It is especially important to have
                   individuals that are not subject to     carefully thought-out protocols in
                   prescribing and dispensing              place to avoid errors. The
 The Colorado      regulations and are readily             Colorado Board of Nursing and the
 Board of          available to consumers without an       Colorado Education Department
 Nursing, the      authorized prescriber’s order.          recommend that districts develop
 American                                                  policies for OTC medications that
 Academy of        These products can be herbs,
                   homeopathic remedies, vitamins,         include permission from parent or
 Pediatrics, and
 the Colorado      remedies for minor ailments,            guardian and a licensed prescriber.
 Education         salves, nutritional supplements,
 Department                                                If districts choose to develop
                   and the like. Just because over-
 recommend                                                 policies that allow school health
                   the-counter (OTC) preparations
 that districts                                            staff to administer OTC
                   can be purchased without a
 develop                                                   medications without a prescription
 policies for      prescription does not mean they
                                                           from an authorized prescriber, the
 OTC               are harmless. Many of these drugs
                                                           medication must be given by the
 medications       have side effects, adverse
                                                           school nurse.26 It is also
 that include      reactions, and interactions with
 permission                                                recommended that protocols
                   other medications and foods.
 from parent or                                            assure that the following
 guardian and      Although the Colorado Nurse             information is provided:
 an order from a   Practice Act does not specifically           The student’s current
 licensed          address the administration of over-          medication profile
 prescriber.                                                    The student’s history of
                   the-counter medications, accepted
                   standards of school nursing                  allergies
                   practice and the American                    Parental consent
                   Academy of Pediatrics                        Appropriate delegation
                   Guideline(2003) identify best                information provided to
                   practice as having prescriber                unlicensed persons responsible
                   orders for all medications, including        for administering the
                   over-the-counter medications. In             medication.
                   Colorado, school nurses generally
                   cover several schools and large         It is appropriate to establish protocols
                   geographic areas. They delegate         that allow the use of preventive
                   the administration of medications       measures such as sunscreen, insect
                   to unlicensed school staff that have    repellent, and diaper ointment with
                   no formal nursing training. Authority   parental permission only.
                   to administer medications that are
                   requested by parents to be given to
                   their children without an order from
                   an authorized prescriber cannot be
                   delegated by the school nurse to        26
                                                             §12-38-132, CRS. Colorado Nurse Practice
                   an unlicensed staff person.             Act.




                                                                                    Page 24 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                    ROLE OF THE SCHOOL NURSE (continued)
                    Over-the-Counter Medications (continued)

                    Never use a drug for children at
                    ages below which the drug is not
                    approved unless it is prescribed
                    by a licensed health care provider
                    and reserve the right to limit the
                    duration the OTC medications are
Just because        given based on parent only
over-the-counter    request. 27
(OTC)
preparations can    Alternatives for the administration
be purchased        of OTC medications include:
without a
prescription does        Requiring prescriptions for all
not mean they            medications, including OTCs
are harmless.
                         Collaborating with a local health
                         care provider who is authorized
                         to prescribe in order to develop
                         protocols for the administration
                         of OTC medications with parent
                         permission

                         Developing policies that allow
                         OTC medications to be
                         administered only with parent
                         permission




                    27
                       American Academy of Pediatrics (2003).
                    Guidelines for Administering of Medications in
                    School www.aap.org/policy/s010105.html.




                                                                     Page 25 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)
              PROTOCOLS FOR THE ADMINISTRATION OF OTC
              MEDICATIONS SHOULD INCLUDE:

                   Drug name                               OTC medications should not be
                                                           stored and administered by
                   Dose specific to weight or age          individual staff members unless
                                                           they have completed the
                   Dosage interval                         Medication Administration training
                                                           and received delegation by a
                   Specific                                registered nurse.
                   indications/contraindications

                   Potential adverse effects


              Homeopathic And Herbal Preparations

              These remedies are viewed by                 These preparations may or may
              many as effective treatments for a           not be recommended by
              wide array of conditions, but lack           practitioners who are licensed to
              substantiating medical or scientific         prescribe.
              evidence.28




              28
                National Association of School Nurses.
              (2006). Position statement: Alternative
              medicine use in the school setting.
              http://www.nasn.org/Default.aspx?tabid=199




                                                                                Page 26 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)

              School-based policies and procedures should consider the
              following issues:
                   The Colorado Medication                      The school nurse is unlikely to
                   Administration29 course does not             be able to safely monitor their
                   include homeopathic or herbal                use.
                   preparations as a routine                    It is generally not urgent that
                   medication so unlicensed                     these products be administered
                   persons have not had training                during school hours; schools
                   specific to these products.                  should recommend that they be
                   All preparations have potential              given at home.
                   side effects, adverse reactions,             If the school nurse is able to
                   and interactions with                        comply with criteria from the
                   medications and foods.                       Nurse Practice Act, then these
                   Dosage requirements are                      medications may be delegated
                   unlikely to exist for the                    on a case-by-case basis.
                   administration of herbal
                   preparations to school age
                   children
                   Herbal preparations are
                   unregulated by the FDA
                   resulting in potential inconsistent
                   amounts of the product and
                   contamination, making a dose
                   variable and unpredictable, a
                   special concern where children
                   are concerned.30




              24
                Guide for medication administration: an
              instructional program for training unlicensed
              personnel to give medications in out-of-home
              child care, school and camp settings (2008).
              http://www.qualistar.org/professionals/mat/php.
              30
                Center for Health and Health Care in
              Schools(2003).Herbal remedies and children:
              Are they safe and effective?
              http://www.healthinschools.org/ejournal/2003/s
              ept4.htm.




                                                                                  Page 27 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)
              Homeopathic And Herbal Preparations (continued)

              The National Association of           NASN also suggests that
              School Nurses (NASN)                  consumers check for an expiration
              recommends that school                date and batch number on the
              policies for alternative or           container, and that they know how
              homeopathic remedies include:         to contact the manufacturer for
                a written order from a health       information or to report a
                care provider authorized to         problem31. School nurses should
                prescribe in that state and that    also consider chronic illness
                includes the condition for which    status, culture, and family tradition
                the product is being used;          and should clarify terms when
                a written request from the          asking adolescents about self-
                parent/guardian to administer       care, over-the-counter
                the remedy;                         medications, or use of other
                verification that the product and   alternative medicines.32
                requested dosage are safe for
                the student (considering age,
                body weight, and condition), and
                reasonable information about
                therapeutic and untoward effects
                and interactions.




                                                    31
                                                      National Association of School Nurses.
                                                    (2006). Position statement: Alternative
                                                    medicine use in the school setting.
                                                    http://www.nasn.org/Default.aspx?tabid=199
                                                    32
                                                      Center for Health and Health Care in Schools
                                                    (2003). Herbal remedies and children: Are they
                                                    safe & effective?
                                                    www.healthinschools.org/ejournal/2003/sept4.h
                                                    tm.




                                                                               Page 28 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                     ROLE OF THE SCHOOL NURSE (continued)
                     Field Trip Medications

                     The school nurse should establish         that the medication was or was
                     procedures to handle                      not given.
                     administration of medications
                     when students go on field trips or        The preparation of individual
                     participate in after-school               doses of medication for field trips
                     activities. The school nurse is           is not considered dispensing
 A child may not                                               according to the Colorado
                     encouraged to prepare the
 be prevented                                                  Pharmacy Board provided the
                     medication herself and not
 from                delegate medication preparation           parents provided the medication in
 participating in    for field trips. If that responsibility   its original container. Generally
 a school-related    must be delegated, the school             preparation of an individual dose
 activity, such as   nurse should include training in          of medication for a field trip can be
 a field trip,       the preparation of field trip             considered part of the
 solely on the       medications in the delegation             administration process. However,
                     training of the person who will be        if multiple doses are required, it is
 basis of a
                     responsible.                              recommended that they be
 special health                                                individually packaged at the
 need.               Although it is recommended that           pharmacy or sent in their original
                     those who administer medications          container with the number of
                     on field trips have medication            doses required for the field trip.
                     administration training, it is
                     recognized that this may not be           For self-directed students, on
                     possible. If necessary, individuals       field trips or at after-school
                     that participate in these activities      activities, teachers or other school
                     may be provided with a case-by-           staff may carry the student's
                     case delegation and a one-time            medication so the student can
                     responsibility to administer              take his/her own medication at the
                     medication(s) that ends when the          appropriate time or students may
                     field trip is over. The school nurse      be given permission to carry their
                     should be reasonably assured that         own medication. The person
                     the person who will be giving the         responsible for the medication
                     medication is a responsible               should report to the school nurse
                     person who is competent to                that it was or was not taken and
                     perform the task. That person             document accordingly.
                     should be provided a labeled,
                     prepackaged dose of the                   (continued on following page)
                     medication, with written
                     instructions about possible
                     adverse effects and reasons not to
                     administer the medication, and
                     should be required to document




                                                                                     Page 29 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)
              Field Trip Medications (continued)

              For students who are not self-         If no alternative can be found, the
              directed, the school has several       medication must be administered
              options:                               by a licensed professional school
                A trained medication delegate        nurse, LPN, substitute school
                can attend the activity and          nurse, or physician employed by
                administer the medication            the district. A child may not be
                Staff that will participate in the   prevented from participating in a
                activity can be provided with the    school-related activity, such as a
                one time responsibility to carry     field trip, solely on the basis of a
                and administer the medication        special health need. 33
                that ends when that activity is
                over even if they have not
                completed the state medication       It is important to remember that
                administration course                the decision to delegate can only
                The parent or guardian may be        be made by the registered
                asked to attend the activity and     professional nurse (RN). The task
                administer the medication, but       being delegated should not
                this cannot be a requirement in      require the professional judgment
                order that their child may           of a registered nurse.
                participate in the activity
                The student's health care
                provider can be consulted and
                may order the medication time to
                be adjusted or the dose
                eliminated for that day




                                                     33
                                                       Administering Medicines to Students
                                                     (Revised Sample Policy): Sample Policy JLCD,
                                                     Rev May 2001.




                                                                                Page 30 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              ROLE OF THE SCHOOL NURSE (continued)
              Field Trip Medications
              (continued)

              Self-Directed Students:
               Know that they must take a
               medication;
               Can recognize that they are
               taking the correct
               medication(e.g. by color or
               shape)
               Know how much they should
               take (either by dose or number
               of pills);
               Know when they should take the
               medication (e.g. before/after
               lunch)
               Acknowledge and comply with
               the responsibilities involved in
               taking their own medication;
               Are assertive enough to refuse
               to take a medication that is not
               the right one.
              Field trip medication should be
              individually prepared for each
              student and the container should
              be labeled with the following
              information:
               name of student
               name of medication(s) to be
               given
               route of administration
               time medication is to be given
               copy of the log to record that
               medication was given




                                                  Page 31 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                       ROLE OF THE SCHOOL NURSE (continued)
                       Experimental Medication

                       The National Association of                          a copy of the detailed consent
                       School Nurses recommends that a                      form signed by the parent/
                       parent’s request to have the                         guardian that describes the
                       school administer experimental                       study (including the potential
                       medications at school should be                      benefits and risks)
                       evaluated on a case-by-case                          the signs and symptoms of
                       basis with the parent, the                           adverse reactions to be reported
                       prescribing health care provider,                    the name and telephone
                       and the school nurse.                                numbers of the investigator or
                                                                            research team, and
                       Clinical trial medications: The                      Written and signed orders from
                       request to administer medication                     the prescriber.
                       at school should be accompanied                   If these criteria can be fulfilled, the
                       by:                                               medication may be administered
                         a copy of the written protocol or               by a RN or delegated on a case-
                         study summary from the                          by-case basis.
                         research organization;


                       Off-Label Use of Medications
Off-label use of
medications refers     Parents or health care providers                    Consent form signed by the
to those drugs         should provide the school nurse                     parent or guardian
that are used for a    with adequate information to                        Written signed orders from the
purpose other          support the safe administration at                  prescriber.
than that identified   school, such as:
by the                   Published anecdotal reports of
                         use in children for the specific
manufacturer.
                         condition for which the
Examples include
                         medication is being prescribed;
Clonidine
                         Manufacturer reports or reports
(normally                from a reliable pharmacy
prescribed to            Current medical journals; or
lower BP) for            Information from a pediatric
ADHD.                    medical or mental health
                         facility.34

                       34
                          National Association of School Nurses.
                       (2001). Position statement: Research
                       medications in the school setting (Experimental
                       and Off-Label Medications in the School
                       Setting).
                       http://www.nasn.org/Default.aspx?tabid=244




                                                                                                Page 32 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                         ROLE OF THE SCHOOL NURSE (continued)
A summary of                                                     35
                         Psychotropic Medications
medications given
should be entered        Doctors prescribe psychotropic               A coordinated process for
on the student's         drugs or brain medications for a             communicating with the family is
cumulative health        wide range of disorders, including           essential for school staff to gain
record (CHR) when        depression, obsessive compulsive             the trust of the family. Many brain
the medication is        disorder, post-traumatic stress              disorders have familial links, which
started and ended,       disorder, panic disorder, social             means family members may be
at the end of the        anxiety disorder, generalized                experiencing the same symptoms
year, at the end of      anxiety disorder, depression,                as the student and may not
a course of              anxiety, enuresis, high blood                perceive the student’s behavior or
medication, or           pressure, ADD/ADHD, tics,                    symptoms as a problem.35
when the dose            Tourette syndrome, extreme
changes.                 impulsivity, drug and alcohol                Parents may not wish the fact that
Examples of              withdrawal aid, ulcerative colitis,          their children are on such
appropriate              childhood growth delay, mania                medications to be known within
documentation:           associated with bipolar disorder,            the school environment. Student
     1/5/02 – Ritalin    migraine prevention, seizure                 confidentiality must be protected
     10 mg daily.        disorders, aggression, and                   as outlined the Family Educational
     5/20/02 – Ritalin   narcolepsy.                                  Rights & Privacy Act.
     10 mg daily
     stopped per
     MD order.
     Ritalin 10 mg
     daily from
     8/15/01 to
     1/10/02.
It is recommended
that medication
logs and
prescriber orders
be retained in the
cumulative health
record for at least
three years or
according to
school district
archival policy.
Logs and orders
                         35
should not be              Brunner, P. (2002). School support for
                         students who use brain medications. School
destroyed if             Health Reporter, Spring 5
summary                  www.Childrenshospitalden.Org.
information has
not been
transferred to the
CHR.34


                                                                                           Page 33 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                             ROLE OF THE SCHOOL NURSE (continued)
                             WHAT ELSE CAN THE SCHOOL NURSE DO?

                             Seek Clarity in Job Description         Improve Medication
                                                                     Management to Ensure Safety
                             For a variety of reasons, there has     and Quality
 “ School nurses             long been lack of clarity of the role
 responsible for             of the nurse who practices in the       The school nurse should work with
 multiple                    school setting. In order to protect     both the administration and staff
 schools or large            themselves, school nurses should        members to develop a system that
 student                     insist that they have a job             will:
 populations                 description that includes their role     prevent error by reducing
 need job                    in overseeing the process of             reliance on memory
 descriptions                medication administration. Those         consider work hours, work loads,
 that reflect their          who already have job descriptions        and appropriate training, and
                             should review them for legality,         make errors visible and in the
 responsibilities
                             preciseness of language and              case of error, mitigate harm.
 more as                     achievability of the individual          For example, attaching a
 consultants                 nurse’s responsibilities with regard     student's photograph to the
 than direct care            to administration of medications         medication administration form
 providers”                  and/or delegatory responsibilities       assists in accurate student
                             and to assure that it is not in          identification when administering
                             conflict with state laws and             a medication. Using electronic
                             regulations.                             technology to enter medication
                                                                      administration information can
                                                                      be an efficient method of
                                                                      tracking documentation and
                                                                      problems.36




 Source: Lear, J. G.
 (2002). Improving safety
 and quality in medication
 management in schools.
 Center for Health and
 Health Care in Schools.
 http://www.healthinschool
 s.org/comm./Medmngmn/
 sld001.htm.                                                         36
                                                                        School Nursing and School Health:
                                                                     Frequently Asked Questions – Records (2002).
                                                                     http://www.cde.state.co.us/cdesped/nurseFAQ.
                                                                     htm.




                                                                                                Page 34 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              §4. THE SCHOOL NURSE AND HER
              COLLEAGUES
              DELEGATION OF RESPONSIBILITY TO ADMINISTER
              MEDICATION

              The Delegatory Clause of the
              Colorado Nurse Practice Act
              authorizes unlicensed personnel
              to administer medications under
              the delegation and on-going
              supervision of the school
              registered nurse. Based on
              school district policy and child
              care licensing regulations,
              unlicensed school personnel who
              are responsible for administering
              medications must complete the
              medication training course that
              has medications are required to
              have staff trained in medication
              administration. This includes
              school programs licensed by the
              Division of Child Care such as
              early childhood preschool
              programs, Head Start and before
              and after school programs.37




              37
                 Guide for medication administration: an
              instructional program for training unlicensed
              personnel to give medications in out-of-home
              child care, school and camp settings (2001).
              http://www.corra.org/CORRAPrograms/MAT.as
              p.




                                                              Page 35 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


                   THE SCHOOL NURSE AND HER COLLEAGUES
                   (continued)
                   WORKING WITH THE SCHOOL STAFF

                   School staff encountering students
                   on medication may be confused              the importance of providing the
                   by the variety of procedures and           school nurse with feedback on
                   issues related to medication               medication effects
                   administration, monitoring, and            the use of appropriate language
The school         effects. In order to safeguard both        for discussing students on
nurse must         students and the school, staff             medication without improperly
                   needs to understand:                       labeling a child and to preserve
work
                     district policies and procedures         confidentiality40
collaboratively      regarding administering
with school          medication                          Unlicensed school staff may bear
colleagues, as       the effects of the specific         a large part of the responsibility in
                     medication(s) that students are     administering medications. As
well as students
                     taking, especially the time when    such, when staff time for this
and their            effects of medication are most      responsibility becomes tight, they
families             likely to occur (both on the        can be invaluable resources for
                     positive and withdrawal sides),     the school nurse who is
                     side effects                        developing a program budget and
                     possible rebound effects (such      planning safe and efficient
                     as the increased irritability,      coverage of health related
                     activity, and inattentiveness       duties.38
                     seen in some children taking
                     stimulant medication
                     necessity of notifying the school
                     nurse if maximum desired effect
                     is not achieved




                                                         38
                                                           Lear, J. G. (2002). Improving safety and
                                                         quality in medication management in schools.
                                                         Center for Health and Health Care in Schools.




                                                                                     Page 36 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              THE SCHOOL NURSE AND HER COLLEAGUES
              (continued)

              EDUCATING STUDENTS, PARENTS, AND BOARD MEMBER
              REGARDING THEIR SCHOOL’S MEDICATION PRACTICES

              Students, parents, board               Prescription and non-prescription
              members, and others in the school      medications that are carried and
              community may not have a clear         self-administered by students
              understanding of the school's          unbeknownst to school health staff
              medication policy, and why it is       can produce adverse effects that
              important, and why it is not "just     may not be recognized.
              another rule." The school nurse
              should work with the school
              community to explain the
              importance of controlling
              medications in school.
                There are many effective, non-
                drug treatments for common
                ailments that can be offered to
                discourage the attitude that
                there “must be a pill for every
                complaint” (e.g. ice for insect
                bites or water for cough, rest for
                headache etc.
                Students may "help" each other
                with OTC remedies they bring to
                school without parent and doctor
                authorization. These may be
                contraindicated in certain
                circumstances
                Younger students may treat
                some OTC remedies, such as
                medicated throat lozenges as
                candy and take inappropriate
                amounts
                Homeopathic remedies can
                intentionally, or unintentionally
                be abused by a child
                Treatment of symptoms may be
                delayed if staff is unaware of an
                acute or chronic health
                conditions that are masked by
                self -administered medication




                                                                         Page 37 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              § 5. RESOURCES
              COLORADO RESOURCES

              Guide for Medication                Frequently Asked Questions and
              Administration: An Instructional    sample health care forms are also
              Program for Training Unlicensed     available on the website or call
              Personnel to Give Medications in    CORRA at (303) 290-9088 x 201.
              Out-of-Home Child Care, School
              and Camp Settings 5th Ed. (2008).   Rocky Mountain Poison Center,
              Qualistar maintains the database    Available 24 hours a day, 365
              of providers who have completed     days per year. Statewide: 1-800-
              the state-approved Medication       222-1222
              Administration training and the
              database for the approved
              Medication Administration RN
              trainers. This curriculum was
              developed by a collaborative team
              of representatives from the
              Colorado Department of Public
              Health and Environment; Healthy
              Child Care Colorado; The
              Children's Hospital; The Colorado
              Department of Human Services,
              Division of Child Care; and The
              Colorado Department of
              Education and is designed to help
              schools, out-of-home child care
              providers, and camp personnel
              safely administer medications to
              children in their care. Topics
              include a medication overview,
              handling and administration of
              routine medications, Epi-Pen®
              training, medication orders and
              documentation, and rights and
              responsibilities. Providers
              needing this training can search
              for approved trainers in their
              county on www.qualistar.org.




                                                                      Page 38 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              RESOURCES (continued)
              NATIONAL RESOURCES

              U.S. Food and Drug                    in Schools - This resource aid is
              Administration, Center for Drug       designed to provide a brief
              Evaluation and Research               overview and some aids and
                                                    information for school
              Recent Consumer Drug                  professionals encountering
              Information - Each of the             students on medication and to
              Consumer Drug Information             address the variety of procedures
              Sheets posted on this site gives      and issues related to medication
              general information about newly       administration, monitoring, and
              approved prescription drugs           effects in the school setting.
              approved since January 1998.          http://smhp.psych.ucla.edu/
              http://www.fda.gov/cder/consumeri
              nfo/default.htm                       Medications - NIH Publication
                                                    No. 08-3929 Revised 2008
                                                    This booklet from the National
              US Pharmacopia                        Institutes of Health is designed to
              US Pharmacopia USP is a non-          help mental health patients and
              government organization that          their families understand how and
              promotes the public health by         why medications can be used as
              establishing state-of-the-art         part of the treatment of mental
              standards to ensure the quality of    health problems. There are
              medicines and other health care       separate chapters for children’s
              technologies. These standards         medications.
              are developed by a unique             http://www.nimh.nih.gov/publicat/
              process of public involvement and     medicate.cfm
              are accepted worldwide. USP has
              prepared materials designed to
              stimulate and guide the
              development of programs and
              materials for teaching children and
              adolescents about medicines.
              http://www.usp.org/audiences/con
              sumers/


              A Resource Aid Packet on
              Students and Psychotropic
              Medication: The School's Role
              School Mental Health Project,
              Dept. of Psychology, UCLA.
              Center for Mental Health Services




                                                                         Page 39 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              RESOURCES (continued)
              National Resources (continued)

              Facts for Families: Psychiatric
              Medications For Children And
              Adolescents - American Academy
              of Child and Adolescent
              Psychiatry
              (AACAP) developed this booklet
              to provide concise and up- to-date
              information on issues that affect
              children, teenagers, and their
              families. Materials are available in
              English, Spanish, Deutsch,
              French, Polish and Icelandic.
              http://www.aacap.org/s/forFamilies




                                                     Page 40 of 42
MEDICATION ADMINISTRATION IN THE SCHOOLS


              § 6. REFERENCES
              1. American Academy of Pediatrics (October 2009). Policy Statement –
                 Guidance for the Administration of Medication in School. Pediatrics. Volume
                 124, Number 4.
              2. Guide to Delegation for Colorado School Nurses (2009). Colorado
                 Department of Education School Health Services website:
                 http://www.cde.state.co.us/cdesped/download/pdf/nurDelegation.pdf

              3. Schwab, N.C., & Gelfman, M.H.B., (Eds.). (2001). Legal issues in school
                 health services: A resource for school nurses, administrators and attorneys.
                 North Branch, MN: Sunrise River Press.

              4. Sheetz A. Blum MS. (1998). Medication administration in schools: The
                 Massachusetts experience. Journal of School Health, 68(3):94-98.




                                                                               Page 41 of 42