Edmonds School District No. 15
Lynnwood, WA 98036-5789

8305-R1 - PROCEDURES FOR DISPENSING MEDICATION AT SCHOOL

Adopted
5/5/80

Revised
9/19/83
7/12/94
1/21/98
9/7/04

4/29/08

1. Administration of Medication:

• The Medication must be administered by a district employee designated by or pursuant to the district’s policy.
• The building Educational Health Specialist (Certificated School Nurse), in cooperation with the building principal, identifies and trains appropriate, designated staff in oral medication administration procedures.
• The medication, whether prescription or Over the Counter (OTC), must be administered in substantial compliance with the prescription of written instructions of the Licensed Health Provider (LHP). Please refer to “Authorization of Medication Administration.”
• The designated staff member must examine the medication to determine that it appears to be in the original container and is properly labeled before administration.
• The designated staff person shall be trained and supervised in proper medication administration by a LHP (RCW 18.79 [Nursing Care]).
• Supply of medications: Parent/guardian supplies medication (prescription and/or OTC in a pharmaceutical or manufacturer’s container. A “school bottle” is typically provided on request at the pharmacy, at no cost to the family.
• Storage: Medication is stored in a locked, secure location and dispensed in accordance with instructions from parent/guardian and licensed health provider.
• Documentation: Records documenting daily oral medication administration are maintained. These records will be maintained for 8 years following administration.

2. Authorization of Medication Administration: Parent/guardian supplies a current and unexpired “Authorization for Administration of Oral Medication at School” form that includes the name of the student, a signed health professional order, and signed permission from a parent/guardian or other persons having legal control over the student (RCW 28A.210.260 [4] ).

• The authorization is valid for the current school year unless a shorter time period is specified.
• Health professionals authorized to order medication administration at school are: Licensed physician and surgeon, dentist, osteopathic physician and surgeon, naturopathic physician, podiatric physician and surgeon, physician assistant, osteopathic physician assistant, or advanced registered nurse practitioner acting within the scope of his/her license (RCW 18.79.260 [1]).

If a medication dosage is changed but the medication is to be administered before the signed request or order is received from the LHP, only a licensed nurse can take verbal/phone/ fax order from the LHP.

• The verbal order must be followed by the written order in a reasonable period of time.
• Faxed orders are considered written orders; the school nurse must be confident that they came from the ordering LHP.
• Prescription bottles with the old order can be used up to ten school days to give parents time to get a bottle with the current order as long as the nurse has a current order, directs the non-nurse school staff to use the available bottle, and the medication provided is consistent with the dosage ordered.
• All new health provider requests or orders for medication should be approved by the school nurse prior to school staff administering the first dose. This is a “best practice” guideline.

3. Discontinuance of Administration of Medication:

• A parent/guardian can discontinue medication administration at school at any time; they can notify designated school staff by written note, telephone call or message, or fax transmittal.
• A school can discontinue medication administration at school if the following conditions are met:
• The chief administrator of the school district or his/her designee must provide notice, orally or in writing, in advance of the date of discontinuance.
• Such notice shall be made to the parent/guardian, or other person having legal control over the student.
• A valid reason for discontinuing medication administration at school must exist; this action cannot compromise the health of the student.

4. Over the Counter (OTC) Medication: OTC medication requires the same medication administration provisions (e.g. written, current unexpired request from a LHP, storage, supply, etc.) The medication administration statute makes no distinction between prescription and nonprescription medications.

5. Inhaled Medications: State law allows administration of oral medication.

• Medications inhaled through the mouth are considered oral medications.
• Medications inhaled through the nose are not considered oral medications, except in the case of a facemask used with a nebulizer or metered dose inhaler. (Per Washington State Nursing Care Quality Assurance Commission Practice Committee, 9/8/00).

To facilitate ready access to inhaled medications, students who are judged to have sufficient maturity should be allowed to carry and self-administer inhaled medications. These students are to comply with medication authorization as outlined in “Authorization” or “Student Self-Administration of Medications.”

6. Medications Administered by Routes Other than Oral: Medications given by routes other than the oral route are considered nursing tasks and regulated by the law relating to nursing care (RCW 18.79).

• Ointments, eye or ear drops, suppositories or injections that are ordered by a LHP can only be administered by student family members, registered nurses (RN’s) or licensed practical nurses (LPN’s), or self-administered by the students.

Administration of medications by routes other than by mouth cannot be delegated to unlicensed school staff except in an emergency situation. Please see section #11 for emergency medication procedures.

7. Student Self-Administration of Medications: Self-administration of medications is not within the purview of the statutes governing oral medication administration. This issue falls under school district policy development. OSPI Bulletin No. 34-01 provides the following guidance:

• Student individual circumstance, type of medication, developmental level, and grade, along with general safety concerns need to be considered for appropriateness of this activity.

Note: e.g. this may be more appropriate at the secondary level than the elementary level.

• Parents are encouraged to consult with the building Educational Health Specialist for appropriateness of medication self-administration.
• Students should carry no more than a one-day supply of medication in a labeled container; the exception to this is multi-dose oral asthma inhalers.

It is preferred for students with self-administered medication to bring a written parent/guardian note. This written permission should be retained in a designated location and turned in to Student Services at the end of the school year with the medication administration records.

8. Emergency Medications: Administration of emergency medications by injection is covered by WAC 246-840-010(10) (b): “Nursing acts delegated by the licensed registered nurse shall not require the unlicensed person to exercise nursing judgment nor perform acts which must only be performed by a licensed practical nurse or registered nurse, except in an emergency situation (RCW 18.79.240[1][b] and [2][b].” Training and supervision by an RN or LHP of non-nurse school staff is recommended for administration of epinephrine to prevent anaphylactic shock in students with known sensitivity to specific allergens (e.g. bee stings, foods, latex, etc.).

• No prescribed medication shall be administered by injection by staff except when a student is susceptible to a predetermined, life-endangering situation.
• Parent/guardian supplies a current and unexpired H-145 Authorization for Administration of Oral Medication at School (formerly Physician’s Authorization for Medication at School) form that includes the name of the student, a signed health professional order, and signed parent/guardian permission.
• The authorization form indicates the sensitive allergen, indications for epinephrine administration, and follow-up measures.
• Parent/guardian is to supply the emergency medication.
• Parent/guardians and the LHP (Licensed Health Provider) are to be notified of any emergency treatment actions.
• A staff member is to be designated by the building nurse or administrator who has the responsibility for carrying emergency medications when students leave school premises but are under the supervision of school staff.
• Emergency medication is to be stored in a secure location; the medication expiration date is to be monitored.
• It is the parent/guardian’s responsibility to keep school staff informed of changes in the student’s condition or changes in LHP orders. They must keep emergency contact information current.
• Record keeping: The staff member who administers the medication has the responsibility to record this activity in the Medication/Treatment Administration Record upon return to school.

9. Training of School Staff in Medication Administration:

• The oral medication statute requires that staff designated by district policy to give medications, are to be trained and supervised by a professional person (RN and/or ARNP) licensed who has delegated medication administration (RCW 18.71 or 18.79).
• OSPI recommends that prior to the beginning of a new school year, district administration or building principals identify at least two staff members per building to administer oral medications for the following year.
• Oral Medication Training is to cover:
• School board policies and procedures governing the administration of oral medications.
• Procedure to follow in administering medication, including a description of when not to administer a medication.
• Procedures to follow in event of a medication error, missed dose, or delayed dose.
• Required medication administration documentation (charting).
• When to contact the supervising nurse.
• Confidentiality issues regarding medication administration and student health information.
• Each building is to maintain a list of staff designated and trained to administer medication.
• The supervising nurse will evaluate the trained staff person’s skill and document the successful completion of the training.

10. Pharmaceutical Issues: The following procedures are based on best nursing practice in relation to procedures for the receipt and storage of medication.

• Receiving and Storing Medication at School:
• It is recommended that the parent/guardian bring medications to school (rather than having the student bring the medication in).
• It is recommended that all medication received by the school be counted by school staff and parent/guardian or a designated adult when brought to school. The number of pills/capsules, or volume of medication should be recorded on a form and the form dated and signed by staff and parent/guardian.
• Note: any discrepancy in the count is to be recorded on a Medication Error Report (H-142) form and sent to the Health Services Chairperson at the ESC.
• It is recommended that the school supply of controlled substances (Schedule II medication, e.g., Ritalin, through Schedule V, e.g., cough syrup with codeine) be counted weekly by a licensed nurse and an assistant (DOH advisory, May 2001). It is recommended that no more than a 20-day (one month) supply of these medications be brought to school by the parent/guardian.
• End of Year Procedures:
• Notify parent/guardian in writing of the need to pick up medication and date of medication disposal if not picked up.
• Send parent/guardian medication and authorization form for the next year.
• Medication left over from the school year is destroyed if not picked up on or after the date specified in the parent/guardian notice. The medication should be counted by two school district staff, disposed, and a statement verifying the counting and disposal should be dated and signed by the staff members.
• All medication forms are to be sent to Student Services and retained until the student is 21 years of age.
• Student Medication Administration Responsibility:
  • It is the primary responsibility of the student to go to the office for their medications.
  • If a student fails to go to the office for any particular dose, school staff should make one attempt per dose missed to contact the student and administer the medication.
• Early Dismissal Provisions:
  • Procedures should be in place for addressing early school dismissal before a regular medication is to be given.
• Divided medication doses:
  • If a tablet must be divided to obtain the correct dose, the pharmacist should be asked to divide the tablet when filling the prescription.
  • If this is impractical, use a single-edged razor or tablet cutters (available at drug stores).

11. Security of Controlled Medications: Medications should be stored in locked cabinets or drawers with access limited to staff designated to administer oral medications.

• Access to medicine cabinet keys should be limited to staff designated to administer oral medications.
• Theft of any drugs should be documented and reported to the Educational Health Specialist Department Chairperson, Program Manager, Building Principal, District Superintendent’s office, and parent/guardian in order to monitor theft.
• Keys to medication cabinets should only be distributed to those who need access to the cabinet and not more than two keys should be made for this same cabinet.
• OSPI recommends storage of medication in a “Substantially constructed cabinet or locked drawer. . . ” to reduce the probability of robbery or pilfering of medication.
• Note: Cabinets constructed of particle board are not deemed “substantially constructed”.
• Non-commercially made cabinets are to be made of metal, solid wood 0.5 inch thick or plywood 0.75 inch thick with nonexposed hinges or nonremovable hinge pins if hinges are exposed.
• A metal filing cabinet with a metal bar capable of being locked into position, blocking the opening of the drawers may be used. This cabinet should be secured to the floor/wall or weighted sufficiently to prevent theft of the entire cabinet.
• In case of drug theft (particularly a large quantity of medication), a report to the local police department may be indicated. Check with your local law enforcement agency.

12. Oral Medication Error Reporting in Schools:

• A medication error occurs whenever a student does not receive medication as ordered by the LHP and requested by the parent/guardian. This includes administration to the correct student at the correct time, in the dosage prescribed, by the correct route.
• Whenever a medication error occurs, a Medication Error Report is to be completed by the designated staff responsible for medication administration.
• All errors must be documented and reported to the supervising nurse for the school within 24 hours (per DOH advisory, May 2001 and RCW 28A.210.260 and 270).
• The supervising nurse, using clinical judgment, will determine the level of severity of the medication error.
• A copy of the Medication Error Report is to be sent to the Educational Health Services Department Chair at the ESC. The supervising nurse may assess the results of actions taken in response to medication errors.
• Examples of medication errors: missed medication, wrong time, wrong student, wrong route, wrong dose, wrong medication, etc.
• A medication error has not occurred if:
• The student is a “no show”.
• One attempt has been made to contact the student and have them come and receive their medication.
• The student does not respond or comply with request.
• NOTE: Best Practice Guideline is to notify the parent/guardian of the situation when possible; this is a “compliance” issue.
• If the error is committed by a credential provider, and causes bodily harm or injury to the student, or causes the student to be seen by emergency services, the incident must be reported by the supervising nurse to:
• The Washington State Nursing Care Quality Assurance Commission, according to WAC 246-840-730.
  Mailing address:
  P.O. Box 47864
  Olympia, Washington 98504-7864
  Telephone number: (360) 236-4700
• The School administrator
• Parents and/or guardians
• The prescriber
• If the error is committed by an unlicensed school employee and causes bodily harm or injury to the student, or causes the student to be seen by emergency services, the incident must be reported to the school administrator, the prescriber, and the parents or guardians by the supervising nurse. The incident may be reportable to the Department of Health, Unlicensed Practice Unit, (360) 236-4659. This may be subject to administrative actions or fines.
• A report of all medication errors will be assembled at the end of each year and a report submitted to the Safety Officer.
• Medication Error Reports will be maintained for eight years after the incident (RCW 4.16.350). The reports will be used by the supervising nurse to:
• Determine trends and patterns in medication errors.
• Assist in identification of educational and resource needs of licensed and unlicensed staff, and
• Record circumstances contributing to the error and actions taken as a result of the error.

13. Field Trips and Medication Administration: All requirements of the oral medication status must be met on field trips (e.g. staff trained and supervised by an RN).

• Parents must be notified well in advance of the field trip (OSPI Bulletin No. 34-01).
• Medication will be carried on the field trip by the designated staff person(s) in a locked, secure fashion (e.g. fanny pack, glove compartment, locked box, etc.) with access limited to those giving the medication.
• Medication should either be:
• In the original pharmacy labeled container.
• In a properly labeled, sealed envelope or plastic bag with the number of doses required during the field trip. In this instance, the school nurse designates a staff person to place the medication in the envelope, record and sign the name of the student, the medication dosage and time of administration on the envelope/bag. This is only appropriate for day field trips (not overnight field trips).
• It is the responsibility of the staff member who administered the medication to document this on the student’s medication log, upon return to school or on a field trip medication log, attached to the daily log on return from the field trip.
• Student with significant medical/health conditions should be provided the opportunity to participate in field trips if that participation is safe.
• The district must investigate whether or not staff can safely accept responsibility for the student who has the right to participate in the field trip and who may require medication during this time.
• There are instances where a student should not go on a field trip because of the unstable/fragile nature of his/her condition and/or the nature of, and/or the distance from emergency care, if that might be required. Possible solutions to the situation are:
• Request parent/guardian accompany student and attend to student’s medical needs.
• Assign an appropriately trained and licensed school staff person to care for the student during the trip.
• The student carries and self-administers his medication. This is appropriate based on the developmental level of the student (e.g. secondary vs. primary) and includes permission from the parent/guardian, LHP, and school nurse.
• If none of these options are possible, the school provides a comparable learning experience at school or in a safe location.

For students who need medications on a field trip that are not normally given during the school day, the authorization to administer medication must be completed and signed by parent/guardian and the prescribing health care provider prior to the field trip. All other medication administration procedures to be followed as in routine school administration of medications.

14. Disaster Planning/Medications: Two elements need to be considered in planning for disaster situations:

• Parent/guardian are asked to supply at least a 3-day supply of medications on hand for students who take medications during the school, AND
• Parent/guardian is asked to identify medication that students take outside of school and to whom the missing of three days of medications would pose a serious health risk for the student or others.

It is the parent/guardian’s responsibility to provide a 3-day supply of these medication and the necessary authorization forms and instructions for these medications.

All medications must be securely and properly stored according to prescription container directions. Attention should be paid to rotation of the stock of medication between home and school to ensure a fresh medication supply at school.

15. Record Retention Requirements: The Office of the Secretary of State and the Washington Association of School Business Officials issued a revision of the “Records Management Manual and General Records Retention Schedule for School District (4/99)”. Health records retention schedules and program-specific records are listed below.

16. "Out of Area" Medication Orders: Out of area medication orders will be accepted on a temporary basis from health care providers in the United States under the following conditions.

• Out of area is defined as outside of the State of Washington.
• Temporary is defined as no more than 30 days.
• Perscriptions for medications (including over the counter medications) must be written in English and be for medications dispensed in the U.S. and that are written in English.
• No medication orders will be accepted for either prescription or over the counter medications from foreign countries (this includes Canada).

  a. We base our procedures on the prescribing authority and limitations outlined by the Department of Health (RCW 69.41.030 and 69.50.101). This is also based on community pharmacy standards.

  b. It is difficult if not impossible to verify the credentials of a foreign health care provider; this includes providers in British Columbia.

• No Medication (including over the counter medications) obtained outside of the United States can be dispensed by school personnel.

  a. The medications prescribed in foreign countries are not consistent with medications ordered in the U.S.

• It is the responsibility of the parent/guardian to provide a current medication order within 30 days of presenting the medication order and medication to the school.
• School Nurses can assist parent/guardians in finding local providers to provide medical care and medication support.

 

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