Policies and Procedures Handbook
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Last Updated: 11/11/2008
Garrett County Board of Education
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GUIDELINES FOR THE ADMINISTRATION OF MEDICATION IN SCHOOLS

Administrative Procedures

Introduction

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:

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.

II.    Narcotics

If a narcotic must be administered in school, the guidelines for prescription medications must be followed with the following modifications: 

III.    Over-the-Counter (OTC) Medications

The administration of over-the-counter drugs will be conducted in accordance with the guidelines for prescription medication.

IV.    Homeopathic 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:

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:

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:

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.

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.

 


                            Appendix C                  

Guidelines For Inservicing Non-Medical Personnel
On Medication Procedures

         Target Population:

            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.

         Introduction:

            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
            (COMAR 10.27.11.05):

  1. 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.

  2. Administration of medication by injection, except a subcutaneous injection if the registered nurse has calculated the dose.
  3. Administration of medications used for intermittent, positive pressure breathing or other methods involving medication inhalation treatments.
  4. Administration of medication by way of a tube inserted in a cavity of the body, except by gastrostomy tube or rectal tube.
  5. Administration of medication by intravenous route.

         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.

  1. Wash hands before and after the procedure.

  2. Compare labeled medication container with written order.
  3. Read label three times.
  4. Check expiration date on label.
  5. Check student's identity with name on label and explain medication administration procedure to student.
  6. Give prescribed dose using prescribed route and at prescribed time.
  7. Record medications on student record sheet.
  8. Relock medicine cabinet.

         Safety Procedures:

            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 container:
                      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.

            Administration Procedures:

            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

                Eye Drops

                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.

                Eye Ointment

                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.      

            6.  Inhalers  

                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.

            Medication Errors:

            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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Pupil Services 472.13
Adopted 
Revised 8/13/81, 1/10/85, 7/14/88, 3/12/91, 8/8/00, 10/14/08