MEDICATIONS IN SCHOOLS: SECTION VI Janie Lee Hall, School Health Advocate Office of School & Adolescent Health NMDOH, Public Health Regions 1&3 Presented by: Lee Carn, RN,BSN, RRPS Broad overview of medications in the schools, and should get you thinking about your own individual situation and send you back with questions for your nurse. Guidelines available in Section VI of the NM School Health Manual. How many of you have medications in your health office? How many of you have read your district’s medication policy?

Definition: A medication is any substance that is ingested, injected, inhaled, or used topically in the diagnosis, treatment and/or the prevention of disease. This includes prescription drugs, over-the-counter and non-prescription drugs, and non FDA-approved herbal/homeopathic remedies. This includes everything from cough drops and throat lozenges and Neosporin to anti psychotics and ADHD medications. The perception is that they are benign–so why the big deal? Allergies, interactions, overdoses, sharing with other students

Options for Medication Administration in School PED licensed professional school nurse (RN) Delegation to appropriate staff (LPN/CMA/UAP/HA) Student Self-Administration (strict criteria) Currently, there are 3 options for giving meds in schools: RNs are licensed to give medications. Delegation: assigning tasks to a properly trained and capable individual Student Self Administration: see next page…

Self-Administration: Students may be allowed to assume responsibility for carrying and administering their own 1-day supply of medications (excluding controlled substances) provided that: Self-administration is approved in writing by the prescribing health care provider, and the parent/guardian; Nurse evaluates the student’s ability to safely & accurately self-administer. Often used for short-term meds such as antibiotic therapy over 10 day period & life-saving asthma/diabetes meds Must carry only what is needed during the school day in the original labeled container.

Guidelines for Medications in Schools Whenever possible, medication should be given at home. Parents must provide the school with written medication orders each school year and each time the order changes Orders must be signed by the PCP and the parent/guardian. The licensed professional school nurse must transcribe the orders onto the appropriate school forms prior to the medication being given. Parent/guardian is responsible for providing the school with a pharmacy-labeled container and all medication Un-used medication should be disposed of or returned according to written school board policy. Key: the professional school nurse should review every medication and order for appropriateness in the school setting prior to the medication being given by anyone. Any change to the original medication authorization requires a new written authorization and a corresponding label change on the bottle or container.

Medication Containers The Label must have the following: Name of the student Name of the medication Drug strength and prescribed dosage Route of administration Time scheduled for administration Name of prescribing health care provider (PCP)

The 6 Rights: Right student Right medication Right dosage Right time Right route Right documentation And, the right reason, That makes 7 1. Know the student – have the student say his/her name and double check stated name with the Medication Administration Record (MAR) and the medication package 2. Always double check the medication name with the order and label, know the purpose of the medication and major side effects. 3. Check three times to make sure you have the correct dose; compare label to MAR; If med looks different, call the nurse/pharmacy that filled the Rx and ask questions 4. Double check that it is the correct time. Medications are given when there is the maximum chance for absorption and the least chance for side effects. Some meds must be given on an empty stomach, before or after meals, or with meal. It is your responsibility to call the student in to take his/her medication if they do not show up on time 5. Double check that you have the right route (oral/topical/rectal/etc) 6. The MAR identifies all six rights; Always check the MAR before giving the medication to verify that it hasn’t already been given. Always chart on the MAR when you give the medication. 7. If the provider writes and order for pain medication for a broken arm, don’t be tempted to give the medication for a headache!

Safety, Safety, Safety!! The Six R’s should be triple checked each and every time medication is administered. First, when taking medication out of storage area. Second, when assisting student with his/her medication. Third, when returning medication to the storage area and documenting. Look at the MAR each and every time you assist a student with his/her medication.

Teach the students to answer these 5 questions: Name (student’s) What is your name? Medication What is the name of your medication or is this your medication? Dose How much do you take? Ordered time to take When do you take this? Purpose of medication Why do you take this? States his/her name, writes it or signs it, points to picture of self, etc. Can identify his/her medication States or indicates amount in some fashion States time, or relates time due to activity/time of day, point to clock, writes it Why the student takes it -- helps me focus, helps me learn, keeps me smooth, so I won’t have a seizure, fit, blank out, etc. Each student should be given instruction regarding his/her own individual medication plan according to the student’s level of ability/understanding.

Administering Medication to a Student: Wash hands between each student Identify each individual student Unlock medication cabinet Take the medication container out of the cabinet Compare the label name and the student name with the MAR before administering the medication Administer medication with out touching Document (6th right) Prepare and give medication in well lighted area. Never leave a medication unattended or out of your sight. Documentation should occur immediately after administration of each medication. At the very least, the student should be able to identify his medication, and refuse when it is not his/hers May enhance with visual aids, pictures on container, etc. Take out only medication for the student in front of you. Only ONE student at a time. Watch student take and swallow medication – check mouth/cheek if need be. If student refuses, that’s ok. Call the parent. Usually the student will comply.

Precautions: Only a licensed professional school nurse can transcribe the original order onto the MAR Only a nurse can take verbal orders or changes in the medication order from the provider. Medication errors or omissions must be reported to the nurse and documented. A medication incident report must be filled out – each district should have one in the school policy. --30 minutes before or after ordered time; otherwise it is a med error

MEDICATION ERROR & INCIDENCE REPORT Errors may include the following: Wrong student Wrong medication and/or dose Wrong route Wrong time Missed dose A medication incident report form is used to report medication errors and must be filled out every time a medication error occurs. Purpose is not punitive! Used as a learning tool in order to prevent recurrences Should include a plan to prevent the mistake from occurring again. (ie. Missed doses are the most common)

Over-the Counter Medications: OTCs are often requested by the parent; Decision to administer requires school nurse’s judgment -- so only a nurse (or the parent) can make the decision to give OTCs; Each district should have a policy for OTC meds. Comfort measures should always be utilized first. Remember that we want to keep kids in class whenever possible and that it is not always possible for parents to come to school to assess their child and give a medication… If your district policy allows: Call the nurse/parent, report what the child has said, how they look, what their temp is, etc., then assist the child to take the OTC if appropriate orders are in place--the key is that your district should have a policy for OTC meds. If medication will be given on a regular basis then a MD order is obtained and it is treated like a routine/daily med. Medications must be approved by FDA for the indicated age group and approved in writing by the parent and be in original packaging, safe and indicated for specific condition, and likely to enable the student to return to class promptly.

Same Day Field Trips Optimally, a separate “single dose” field trip supply of medications (in an originally-labeled pharmacy container) should be made available by the PCP and parent/guardian Alternately, the originally-labeled school supply should be checked out to the adult who is trained and delegated by the school nurse to administer the medication Refer to your district policy. Extended Field Trips – before or after the duty day; parent makes arrangements with school staff and provides medications from home supply.

State Laws: Each local education agency must adopt a written policy that meets its students’ needs for prescription and non-prescription drugs. All schools are required to authorize students to carry and self-administer asthma treatment medications, anaphylaxis emergency treatment medications, and diabetes treatment medications (under specific conditions). Conditions for self-carry/self meds: *appropriate instruction has been given by the provider to the student in the correct and responsible use of the medication; * the student has demonstrated adequate skill level to the school nurse to carry and self administer identified medication; *there is a written treatment plan on file with the school nurse; *the school liability policy and the extent and duration of the authorization has been discussed with the parent/guardian.

Emergency Medications: Albuterol, Epinephrine, Glucagon & Oxygen The School Nurse is responsible for training adult employees to administer these emergency medications when they are ordered at school. Appropriate delegation and training records are necessary, with regular updates of training documented; usually HA, classroom teacher or EA, etc.

Medication Storage: Routine medications should be stored in a locked cabinet in a secure area; FDA guidelines and national standards require that all controlled substances be stored in a double locked narcotic cabinet that is equipped with two separate locks and keys. Controlled substances include narcotics and ADHD medications such as Concerta and Ritalin. Only authorized persons may have access to the keys and med cabinet; -it is never appropriate for the student to unlock the med cabinet. Only authorized, trained adults may have access to keys -- NEVER allow a student to unlock the cabinet. A cool, dark place is recommended (unless otherwise indicated). Oral medications must be stored on a separate shelf from topical medications. Medications for external use are stored separately from internal drugs. Disinfectants and poisons are stored in a separate, locked area.

Refrigerated Meds: Antibiotic elixirs usually require refrigeration. The refrigerator should be in a secure area and not be accessible to unauthorized individuals. Food should not be kept in the same refrigerator as medications. The temperature should be checked daily when school is in session and should be maintained between 36 and 46 degrees Fahrenheit.

TRANSPORTING MEDICATION: Each school district should develop a written School Board policy addressing the issue of transporting medications. Topics to cover in this policy might include the following. Medications transported to school Medications transported from school Medication transportation for emergency evacuation during the school day It is strongly recommended that parents transport medications to school rather than giving them to the child to turn in. For your own protection, you should NOT send meds home with the student. Parent needs to pick them up. There should be a policy for destroying meds not picked up at the end of the year. Count sheet showing written documentation for medications received, given, returned, disposed of. Always requires two people to count and document controlled medications.

Disposing of Medications Parents should be notified that it is their responsibility to pick up any unused medications Never give students unused medications; even if parent instructs you to do so PED licensed RN should dispose of unused medications with adult witness Recommend counting the number of school days left when calling and requesting additional meds from parents during the last month of school to avoid waste and inconvenience to the parent. Disposal Sheet -- do not flush meds. Crush and place in baggie with kitty litter or lotion, etc. Throw away.

To Ensure Maximum protection: Use approved prescription and over the counter authorization forms for parents and providers with signatures yearly and as needed. The PED licensed school nurse must review, transcribe and sign all medication authorization forms. Parent/guardian is responsible for providing the school with the medication in a pharmacy labeled container or the original manufacturer’s container. Authorization forms apply to both prescription and non-prescription medications, daily and prn orders. No medication should be given until the nurse has transcribed the order and determined the appropriate mode of administration (delegation/sup. Self admin, etc) Parents are welcome to come to school to administer the med until everything is in place. Unused medication should be disposed of or returned according to written district School Board policy.

Remember: Always exercise great care with medications to ensure the safest possible care for students. Keep students and yourself safe by meticulously following state guidelines and school district medication policy. When in doubt, ALWAYS ask the school nurse!

NOTE: Poison Control (800-222-1222) is a valuable resource when you have questions about a medication.

QUESTIONS?