|Policies and Procedures Handbook|
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Last Updated: 11/11/2008
Garrett County Board of Education
40 South Second Street
Oakland, MD 21550
GUIDELINES FOR THE ADMINISTRATION OF MEDICATION IN SCHOOLS
The administration of medication in the school setting is a service offered to parents and students to promote wellness and decrease absenteeism. When there is a need for a student to receive medication in school, safe and proper administration is essential.
I. Prescription Medication
A. Medication Authorization
All prescription medication to be given in school must be ordered by a person authorized to prescribe medication in Maryland. Maryland law defines authorized prescriber as physician, nurse practitioner, certified midwife, podiatrist, physicianís assistant or dentist. (Section 12-101(b) Health Occupations, Annotated Code of Maryland)
The order must be signed by the authorized prescriber. In lieu of a written signature, a stamp with the prescriberís signature or electronic signature is acceptable; however, a printed name stamp is not acceptable. A medication authorization form must accompany each medication order. An order should be renewed annually even if the order is for a (whenever necessary) medication. The authorization should be filed in the studentís school health record. See Appendix A.
Verbal orders from an authorized prescriber may be taken only by a registered nurse (RN) or a licensed practical nurse (LPN). This order should be recorded by the nurse in the studentís medication record and must be followed up, within ten days, by a written order from the prescriber. If unable to obtain the written order, the nurse should attempt to contact both the prescriber and parent/guardian. If the written order is not received within ten days, administration of the medication must be discontinued in school.
Faxed orders for the administration of medication may be accepted when submitted on an authorized form and signed by an authorized prescriber. The parent/guardian should sign the authorization within ten days. The authorization should be filed in the studentís health record.B. Parental Consent
Written parental consent is required for each medication ordered and for each new order (even if the medication was previously given in school). See Appendix A.
In the case of verbal orders from an authorized prescriber, verbal consent from the parent should be obtained and documented, to be followed by the written consent within 10 days.
Parental consent forms should be filed in the studentís school health record.C. Labeling, Storage, and Disposal
The original prescription container should accompany all medications to be administered in school. Parents should request two containers (one for school and one for home) from the pharmacist when getting a prescription filled. Medications should be brought to the school by the parent or responsible adult, especially for elementary school students. However, if this is not possible, the parent/guardian should inform the school nurse, principal, or designee by telephone that his/her child is bringing the non-narcotic medication to school and how much of the medication is in the container. This alleviates any questions about how much medication should have been in the container when the child reached the school. The amount of medication received should be checked by the school nurse, principal, or designee and documented as soon as the student delivers the medication, the exception being narcotics.
The original prescription container should be labeled with the following:
Name of student.
Name of medication
Dosage of medication to be given.
Frequency of administration.
Route of administration.
Name of physician/authorized prescriber ordering medication.
Date of prescription.
In compliance with the School Health Standards (COMAR 13A.05.05.05--.15), all medication must be stored in a locked cabinet. Medications that must be refrigerated must be stored in a locked box in the refrigerator. Access to medication locked in the designated space shall be under the authority of the designated school health professional, the principal, and/or designee.
All medication must be destroyed one week after the expiration date or at the end of the school year. If not retrieved by a parent or responsible adult, unused and unclaimed medication should be disposed of by flushing. Empty asthma inhalers may be disposed of in the trash. Sharps (needles, lancets) should be disposed of in a puncture proof container. Puncture-resistant biohazard containers will be used for the disposal of all sharps such as needles, syringes, and lancets. These containers will be ordered by the facility or school nurse or designee through the Maintenance Office and will be stored at each work site with other medical supplies. Containers will be placed in every room where sharps are used. All biohazard sharps containers must be under the control of a staff person when in use and/or stored in areas where they are inaccessible to the public. When the container is three quarters (3/4) full, treat the contents with bleach, turn the top to the locked position and place the container in the regular waste. Containers will be placed only in buildings where sharps are used. (Garrett County Exposure Control Plan)D. Administration of Medication
The designated school health professional, in collaboration with the principal, implements the medication policy. School staff and parents should be informed of the medication policies and procedures annually.
The parent/guardian should give the first dose of any new prescription or over-the-counter medication, except for emergency medications (e.g. Epi-Pen);
Prescription medications should be counted when sent to school. The designated school health professional should record and sign the MAR along with that of a witnessing parent/guardian or a responsible employee.
A record must be maintained each time a medication is administered. See Appendix B Students who self-administer must inform the designated school health professional, principal or their designee of the need for medication, as soon as possible.
A plan should be developed by the school nurse, parent/guardian, and physician, and should address how to keep records of administration. It must be determined by the nurse whether a student who self administers medication is responsible to self carry their medication. The developmental ability of the student, the need to have ready access to emergency medication and the safe storage of medication must be taken into account when making this decision.
If a narcotic must be administered in school, the guidelines for prescription medications must be followed with the following modifications:
The parent/guardian shall bring the medication to school.
The amount of the drug received should be immediately counted and recorded by the school health professional and/or designee, witnessed by a responsible employee.
The narcotic should be counted on a scheduled basis by the designated school health professional and witnessed by a responsible employee. This count should be reconciled with the prior count and medication administration record.
The school nurse should maintain no more than a 30 day supply of narcotics.
There must be a new order and parent authorization every 30 days EXCEPT if the narcotic is to be given whenever necessary. If the narcotic is to be given for more than thirty days, the designated school health professional should contact the parent or prescriber to confirm the continued need for the medication.
III. Over-the-Counter (OTC) Medications
The administration of over-the-counter drugs will be conducted in accordance with the guidelines for prescription medication.
Nurses may administer over-the counter drugs only with verbal or written prescriptive order from an authorized prescriber.
Storing and recording the administration of the over-the-counter medication should follow the same guidelines as prescription medications.
IV. Homeopathic Medications
Administration of homeopathic medicines will be conducted in accordance with the guidelines for prescription drugs.
Storing and recording the administration of the over-the-counter homeopathic medication should follow the same guidelines as prescription medications.
V. Delegation of Medication Administration to Unlicensed Staff
Plans for the administration of medications in the absence of the nurse should be developed collaboratively by the school nurse and the principal. The decision regarding delegation of medication administration should be considered in conjunction with other school duties, such as lunch and recess supervision. Such comprehensive planning will ensure that the most appropriate person is assigned to each task and that medication administration is completed in a safe manner.
Criteria for Personnel Selected to Administer Medication in the Absence of the School Nurse: In all cases, the person to whom the nurse delegates the administration of medications should meet criteria set forth in COMAR 10.27.11 and COMAR 10.39.01.
In the judgment of the nurse, the task delegated can be properly and safely performed by the unlicensed individual or certified nursing assistant without jeopardizing the clientís welfare. In the nurses judgment, the person must be competent to perform the task assigned. Additionally, the person should:
Be an employee and agree to this responsibility.
Have good attendance.
Be familiar with the students in the school.
Possess good organizational skills.
Handle stress in a calm manner.
Have coverage/assistance available for regularly assigned job duties during peak times when medications must be given (usually between 11:00 a.m. - 1:00 p.m.).
Be in a quiet environment which allows for safe and effective medication administration.
Since the majority of medication doses are scheduled for administration between the hours of 11:00 a.m. and 1:00 p.m., plans must include considerations for the personís lunch.
COMAR 10.27.11.05G and COMAR 10.39.01 requires that persons administering medications under the direction of a nurse be appropriately trained and supervised. Persons administering medication must be trained by using the School Health Medication Administration Training Program approved by the Maryland Board of Nursing. This training provides instruction in the administration of oral medication. Administration of medication by any other route requires the delegating nurse train the unlicensed person on a one-to-one basis. Records of the date and nature of the initial training and every two year re-certification must be maintained.
Periodic direct supervision by registered nurses of personnel assigned responsibility for medication administration will occur. Registered nurses will maintain records of this supervision using the Medication Administration Skills Checklist, which is to be completed every 45 calendar days. (See Appendix C)
Each person assigned routine responsibility for medication administration should have at least one person designated as an alternate to substitute in the case of absence. Selection and training of alternates should follow the same process outlined above.
Persons assigned responsibility for medication administration should have regular opportunities to administer medications in order to reinforce training and ensure that best-practice skills are maintained.
Medication administration is not an appropriate assignment for a school volunteer.
VI. Administration of Medication on School -Sponsored Activities
Medications should be administered to students on school sponsored trips and activities only when absolutely necessary, and when possible, timing of doses should be adjusted to occur outside of the school-sponsored activity period. Medications may be administered on school-sponsored trips and activities only when previously administered and a parent permission form is on file. The determination of whether a medication is administered during a school-sponsored trip or activity and by whom should be determined by the designated school health professional in collaboration with the principal and parents. Options for administration of medications during a school-sponsored trip or activity may include the following:
Parent/guardian may accompany student on the school-sponsored activity and administer the medication.
A single dose of the medication can be placed in a properly labeled envelope or container by the licensed nurse only to be given on the school-sponsored activity by school personnel.
A parent may send a single dose of medication for the field trip in a properly labeled prescription or over-the counter container to be given by school personnel.
Following the school-sponsored activity, the single dose medication envelope should be returned to the heath suite with documentation of signature and time medication was given. A notation should be made on the studentís medication record that the medication was administered.
VII. Errors in the Administration of Medication
If an error in medication administration occurs (such as missing a dose, giving the incorrect dose, giving incorrect medication to the student, or giving a student another studentís medication even if the medication was same drug and dose), the procedures below should be followed:
The student should be observed for untoward side effects from incorrect medication administration.
Appropriate action should be taken based on nursing judgment and/or physician order.
The parent, school administrator, nursing supervisor and primary care provider of the child getting the wrong medication should be notified.
The appropriate reporting form should be completed (See Appendix D).
Submit written incident report within 48 hours to the Supervisor of School Health Services.
VIII. Stolen or Lost Medication
If any medication is reported missing, the school administrator should be notified and procedures for missing property on school grounds followed. Since the incident involves drugs, notification of the police may be appropriate. Parents should also be told so the medication may be replaced. The appropriate reporting form must be completed and the designated school health professional should keep a copy of the report. (See Appendix D.)
IX. Self-Administration of Asthma Inhalers and Other Emergency Drugs
Students may possess and self-administer an asthma inhaler or other emergency drug that is dispensed for a student only on the prescription of a health practitioner and pertains to the studentís asthma or other airway-constricting disease. Students may possess and self-administer this medication while in school, at school-sponsored activities or on a school bus or other school property if the following conditions are met.
Must have prior written order from the health care provider on the Medication Order Form.
Must have prior written approval of the parent or guardian on the Medication Order Form.
The school nurse shall assess the studentís ability to demonstrate the skill level necessary to ensure proper and effective use of the medication in school. (See Appendix E)
A student may be subject to disciplinary action if the student does not use the medication in a safe and proper manner.
Written authorization from the health care provider and parent, and assessment by the nurse should be done annually for the student to be able to self-administer these medications.
Documentation of the above process and health care providerís order must be maintained in the studentís health records.
Annotated Code of Maryland Education Article &-421
X. Communication With Physicians Regarding Treatment of a Student
If the school nurse has concerns about the medical orders, or wants to share information that may be relevant to the treatment regimen with the physician, the school nurse and physician may communicate with each other regarding the medical orders and treatment regimen without written authorization of a parent. HIPPA allows health care professionals to share protected health information if it is for treatment purposes. Furthermore, regardless of the healthcare setting, state licensure statutes and professional standards of practice for nurses and physicians require nurses to question and clarify medical orders, when indicated, before carrying them out. They also require physicians to provide nurses with sufficient information for safe execution of the treatment plan. Therefore, such communication is based on state law and necessary.
Guidelines For Inservicing Non-Medical Personnel On Medication Procedures
Any non-medical and/or unlicensed health personnel (i.e. teachers,
administrators, secretaries, and school health aids)
who are at times assigned to supervise students who take medication during the school day.
The trained school nurse may use these guidelines to provide inservice
education to those non-medical and/or
unlicensed health personnel designated by the nurse and the principal to supervise students who require medication
during the school day. At all times, decisions to delegate medication administration must comply with the Nurse
Practice Act, COMAR 10.27.11, Delegation of Nursing Functions. The following activities may not be delegated
Calculation of any medication doses, except for measuring a prescribed amount of liquid medication and breaking a tablet for administration if the registered nurse has calculated the dose.
Preparation for Administration:
These general procedures should be used prior to the administration of any medication. They should also be used as the basis for the supervision of non-medical and/or unlicensed health personnel who are administering medication.
Wash hands before and after the procedure.
When medication is administered, certain safety rules, called the Five Rights, must be followed.
The Five Rights
1. Right medication
A. Compare physician order three times, with label on medication
1. When taking medication from storage area 2. Before placing medication into lid/medicine cup/mouthpiece 3, Before returning medication to storage area
B. Know action, dosage, and method of administration.
C. Know side effects of the drug.
2. Right patient
Ask the student his/her full name and compare name with medication order and label.
3. Right time
Check time with written order.
4. Right method of administration
5. Right amount
Compare physician order with medication container label.
When administering medication, remember: check the order with the label three times.
1. Oral Medication
A. Student should sit or stand.
B. Pour the tablet from the bottle into the lid of the container (and then into the medicine cup, as necessary).
C. Pour liquid by setting medicine cup on a firm surface at eye level and read fluid level at the lowest point of the
meniscus (the curved upward surface of a liquid in a container). Place lid upside down to avoid contamination and
pour with label facing up to avoid obliterating label. Wipe bottle off before replacing cap.
D. Return medication to cabinet or refrigerator. Lock cabinet.
E. Unless contraindicated, offer a fresh glass of water to aid in swallowing, to camouflage the taste of bitter
medications, and to assure that medication is washed into the stomach.
F. Make sure the student swallows the medication.
G. Discard used medicine cup.
H. Record the medication on the appropriate forms.
I. Observe student for any immediate medication reaction or side effects.
2. Topical Medications (ointments and salves)
A. Gather necessary equipment, including gloves or tongue blade as needed. B. Squeeze medication from a tube or use a tongue blade to take ointment out of jar. C. Spread a small, thin quantity of medication evenly on bandage to be placed on skin. Use a tongue blade to facilitate smooth application of ointment. D. Protect skin surface with a dressing and use tape or gauze to secure in place. E. Remove gloves and wash hands. F. Return medication to medication storage cabinet. G. Record the medication on the appropriate forms. H. Observe student for any immediate medication reactions or side effects.
3. Eye Medications
A. Explain procedure to student. B. Give tissue to student for wiping off excess medication. C. Have student tilt head slightly backward and look up. D. Squeeze the prescribed amount of medication into the eye dropper. Hold dropper with bulb in uppermost position. E. Place eye dropper one-half to three-fourths inch above eyeball with dominant hand. F. Stabilize hand holding dropper as necessary. G. Expose lower conjunctival sac (mucous membrane that lines eyelids) by pulling down on cheek. H. Drop prescribed number of drops into center of conjunctival sac. I. Repeat procedure if student closes eye and drop falls on eyelid. J. Ask student to gently close eyelids and move eye to assist in spreading medication under the lids and over the surface of the eyeball. K. Remove excess medication with clean tissue. L. Wash hands. M. Replace medication in medication cabinet. N. Record the medication on the appropriate forms. O. Observe student for any immediate reaction or side effect.
Same as above except for the following application:
A. Gently separate patient's eyelids with thumb and two fingers, and grasp
lower lid near the margin of the lower lid
immediately below the lashes.
Exert pressure downward over the bony prominence of the cheek.
B. Student should look upward.
C. Apply eye medication along the inside edge of the entire lower eye lid, starting at the inner corner.
4. Ear Drops
A. Position student on side, with ear to be treated in the upper-most position. B. Fill medication dropper with prescribed amount of medication. C. Prepare student for instillation of ear medication as follows: Infant: Draw the earlobe gently downward and backward. Child: Lift ear upward and outward. D. Instill medication drops, holding dropper slightly above ear. E. Instruct student to remain on side for 5-10 minutes following instillation. F. Student should lie in the same position for 1-2 minutes to ensure medication is absorbed. G. Dispose of used supplies and wash hands.
5. Nose Drops
A. Student should be in a sitting position with head tilted back, or in a supine (lying on back) position with head tilted back over pillow. B. Fill dropper with prescribed amount of medication. C. Place dropper just inside the nostril and instill correct number of drops. D. Instruct student not to squeeze the nose and to keep head tilted back for five minutes to prevent medication from escaping. E. Return medication to medication storage cabinet. F. Record the medication on the appropriate forms. G. Observe student for any immediate medication reaction or side effect.
Have the student:
A. Put mouthpiece on canister.
B. Stand up.
C. Shake inhaler for two seconds.
D. Position inhaler with canister above mouthpiece (upside down).
E. Hold mouthpiece one inch from lips and open mouth wide.
This position allows the student to:
1. Point the inhaler properly toward the back of the throat.
2. Draw the medicine into mouth in a steady stream.
3. Check to see that the medication is being properly inhaled.
Putting the lips around the mouthpiece as directed in the package instructions
may prevent the student from
getting the full dose because: 1. The mouthpiece may be misdirected. 2. Much of the medicine hits the cheeks and palate because of turbulence on release. 3. No one can check to see that timing is right. F. Breathe naturally. G. Open mouth and begin to inhale. H. Squeeze canister on mouthpiece and take about two seconds to inhale as deeply as possible. I. Hold breath for as long as possible up to ten seconds. J. Assess student's condition to ensure the medication has helped.
1. As soon as an error in the administration of medication is recognized, initiate the following steps:
A. Keep the student in the health room. If student has already
returned to class when the error is determined,
have someone accompany student to the health room. B. Observe the student's health status and notify the designated school health professional of the error and the
student's health status. C. Identify the incorrect dose or type of medication taken by the student. D. Notify parents. E. Immediately notify the supervising nurse coordinator or specialist and the principal/designee of the error. F. Notify student's physician.
G. If unable to contact physician, contact the Poison Control Center at (410) 528-7701 for instructions. 1. Give the name and dose of the medication taken in error. 2. Give the age and approximate weight of the student. 3. Give the name(s), dose(s), and time of last dose of other medication being taken by the student if possible. H. Follow the instructions from the Poison Control Center, if at all possible. If unable to complete their directions,
explain the problems to the Poison Control Center to determine if the student should be transported for emergency medical care. I. Carefully record IN INK (in the student's health record on the continuation sheet) all circumstances and actions
taken, including instructions from the Poison Control Center and student's status. J. Submit an incident report within 48 hours to the Assistant Superintendent of Schools or designee.
Medication Order Form
Medication Forms For School Use Only
Medication Administration Skills Checklist
Incident Report For Medication Treatment Error Or Stolen/Lost Medication
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Table of Contents
Pupil Services 472.13
Revised 8/13/81, 1/10/85, 7/14/88, 3/12/91, 8/8/00, 10/14/08