Medication Administration Procedures

It is important that these principles of medication administration be known and followed by anyone (nursing and non-nursing personnel) who is administering medications. The RN/LSN can use these principles as a guide to develop and write school specific procedures.

If a school does not have a RN/LSN employed or under contract, the school should consider consulting with a licensed health care provider. Appropriate procedures, designed for the school and the school personnel administering medications is needed to provide safe and effective care to the student and to reduce risk of school personnel performing duties outside of their job description or practicing nursing.

Medication administration procedures may need to include differentiation for medication administrated on a routine, emergency, or as needed basis and the route of administration: oral, inhaled, topical, rectal, intravenous, pumps, gastrostomy-tube, intramuscular, subcutaneous, or ear and eye. MDH information for Health Professionals about injection Safety is a good resource for injections.

Principle 1: Use infection control measures including hand washing/hand sanitizer before/after medication administration, gloves (when appropriate) and handling the medication to avoid touching.

Principle 2: Review authorization forms/records in the student’s medication administration record (MAR) or the student health record as required per school policy each time the medication is to be administered.

Principle 3: Use and follow the Six Rights of medication administration each time the medication is to be administered. The right student, the right medication, the right dose, the right route, the right time, and the right documentation.

Principle 4: Prevent errors! Minimize distractions and interruptions in the space/time of medication administration. Do not use one student’s medication for another. Never leave the medication unattended.

Principle 5: Provide respect and privacy to student during medication administration.  

Principle 6: Documentation in the MAR or student health record, verifying student name, time given, medication name, dose, route, name, and title of person administering the medication, and any unusual observations.

Principle 7: A clearly outlined procedure for reporting medication error, including omissions or student refusal. This includes who (parent/guardian, RN/LSN, school administrator, licensed prescriber) and when (specific time frame), and how notification will occur. The RN/LSN along with school administrator should evaluate errors/incidents as a risk reduction and quality improvement for student safety.

The Six Rights of Medication Administration

The six rights are fundamental for safe medication administration. The National Association of School Nurses (NASN) has developed a Toolkit for Medication Administration in Schools which provides a comprehensive Six Rights of Medication Administration checklist. This checklist provides a guide to using the six rights when a medication is received from a parent/guardian and when administering the medication to the student. Schools are encouraged to post The Six Medication Rights in any area where medication administration occurs.

Right student. Properly identify the student before administering the medication. Ask the student to state their name, rather than asking “Are you Jane Doe?” If available, check the student’s photo.

Right medicine. Administer the correct medication. Check three times, prior to administration.

Right dose. Administer the right amount of medication. Use standard medication dosing instruments. Do not use kitchen utensils (tablespoon or teaspoon).

Right route. Use the prescribed method (i.e., oral, inhaled, nasal) of medication administration.

Right time. Administer medication at the prescribed time. This can usually be within 30 minutes earlier or later than the designated time unless otherwise specified by the provider or the pharmacist.

Right documentation. Promptly and accurately document the medication administration.

The requirements and the procedure for receiving or obtaining licensed prescriber and parent/guardian authorization should follow district policy.

Licensed Prescriber Authorization

No prescription medication may be administered without the written order of a licensed prescriber. Policy, Roles, and Responsibility of School Personnel covers who is a licensed prescriber in Minnesota. The written order of the prescriber should clearly indicate the student’s name, the medication name, the dose to be administer, the route to administer the medication, the time the medication is to be given, provider signature, date, and contact information. If the medication is to be given “prn” (as needed) the conditions to administer the medication should be specific such as “headache longer than 30 minutes” or ‘pain that does not resolve in 15 minutes with rest/relaxation”. The nurse/school should never hesitate to clarify a “prn” order with the provider. This ensures safe medication administration.

The best practice recommendation would be for the provider to use the school’s authorization form, but each school policy must determine if authorization is accepted in another format.

Licensed provider authorization must be updated if there is a change in the medication such as dosage or time and must be renewed at the start of every school year. The licensed provider authorization should match the pharmacy labeled bottle. If a change occurs during the school year the nurse/school administrator should work with the parent/guardian or pharmacy directly to receive an updated pharmacy labeled bottle.

Specific to emergency medications, the licensed prescriber should use a standard asthma action plan, seizure action plan, anaphylaxis/allergy action plan and a diabetic management plan. These plans can clearly identify the signs/symptoms the student may experience to direct school staff when and how to administer medication and any other steps needed to care for the health emergency such as calling 911.

Minnesota Statutes § Chapter 121A.22 specifically states “epinephrine auto-injectors, consistent with section 121A.2205, if the parent and prescribing medical professional annually inform the pupil's school in writing that (i) the pupil may possess the epinephrine or (ii) the pupil is unable to possess the epinephrine and requires immediate access to epinephrine auto-injectors that the parent provides properly labeled to the school for the pupil as needed.”

Schools should determine if licensed prescriber orders are required for over-the-counter (OTC) medications. Not all OTCs are equal and many of them were prescribed medications previously and come with specific indications/warnings related to their administration. The school district board and school personnel need to carefully consider Federal Drug Administration (FDA) warnings and the student safety ramifications if they choose to allow OTC medication administration without a prescription. If a decision is made to administer OTC medication without orders from a licensed prescriber, directions should be taken from the official container’s manufacturer’s label.

State of Minnesota Office of the Attorney General Letter (February 14, 2000)

In 2000, the Attorney General was asked to provide an opinion as to whether school nurses could provide over-the-counter (OTC) medications to students upon a parent’s request, even without a physician’s order. The State of Minnesota Office of the Attorney General Letter concludes, “this office concludes that school nurses do have the authority to provide over-the-counter medications to students upon a parent's request, even without a physician's order. It is important to note, however, that the school nurse has the ultimate authority and responsibility to reject a parent's request and to decline to administer an over-the- counter medication if the nurse believes that such medication is unnecessary, inappropriate, or could lead to patient harm. Further, school districts retain independent authority to implement policies that govern the administration of non-prescription drugs by school nurses. A school district, or an individual nurse, could choose to adopt a policy that requires a physician's order before a school nurse administers a non-prescription medication to a student.”

Parent/Guardian Authorization

Minnesota Statutes § Chapter 121A.22:

• “The request of a parent may be oral or in writing. An oral request must be reduced to writing within two school days, provided that the district may rely on an oral request until a written request is received.
• “prescription asthma or reactive airway disease medications self-administered by a pupil with an asthma inhaler, consistent with section 121A.221, if the district has received a written authorization from the pupil's parent permitting the pupil to self-administer the medication, the inhaler is properly labeled for that student, and the parent has not requested school personnel to administer the medication to the pupil. The parent must submit written authorization for the pupil to self-administer the medication each school year.”
• "epinephrine auto-injectors, consistent with section 121A.2205, if the parent and prescribing medical professional annually inform the pupil's school in writing that (i) the pupil may possess the epinephrine or (ii) the pupil is unable to possess the epinephrine and requires immediate access to epinephrine auto-injectors that the parent provides properly labeled to the school for the pupil as needed.”

Each school should develop a parent authorization form whereby providing consent for the school to administer the medication. Many districts elect to have a combination form that includes the licensed prescriber authorization as well. A best practice recommendation is to include parent/guardian authorization for the nurse to specifically talk to the licensed prescriber should there be questions or concerns specific to that medication and the child’s health condition. Safe medication administration and nursing standards of practice require nurses to communicate to the license prescriber for questions or concerns.

District policy/procedure should specifically state if the parent/guardian authorization applies only for the regular school day or may be used for before/after school and extracurricular activities.

Parent/guardian authorization must be renewed at the start of every school year or if the parent makes a change in the request.

School health personnel should maintain accurate written or electronic records specific for each student receiving medications, including parental consent forms, authorization from licensed prescribers, self-carry authorizations/contracts. Nurses should also include any communication to the licensed prescriber or parent/guardian regarding the medication.

Documentation must contain student name; name of medication; purpose, dosage; route; date and time given; beginning and end dates; any special circumstances related to the procedure, the student’s unusual reactions or responses, omissions, absences, or refusals, name/title of the individuals giving the medication, count of controlled substances, and medication disposal.

All health services staff (nurses, health offices unlicensed assistive personnel) administering medication should document promptly after administering medication to the student.

Documentation in paper must be done in unalterable ink (no erasing, no deleting/white out) and legible. Electronic documentation should meet all safety and legal requirements to insure data privacy and accuracy. No person should alter or change the documentation made by another health services staff member; any corrections should be noted separately. Medication administration records are legal documents and should be secure to protect student privacy.

Medication administered to the wrong student, or wrong medication dose (including missed dose), time, or route are medication errors and are recorded in the student record and on an incident report form.

Ideally parents/legal guardians deliver all medications to the school, but it should be required for controlled substances. If a medication will be brought to school by another adult or the student, the school should be notified in advance so appropriate steps can be taken to ensure the medication is retrieved promptly upon arrival to school and secured in the health office.

Schools should count all medications brought to school but must count all controlled substances. Documentation should include person bringing the medication, date received, type and amount of medication received. In addition, controlled medications should be counted after each administration of the medication to the student.

All medications should be stored on school property, in a locked drawer or cabinet used exclusively for medications. Cabinets should not contain glass doors and should be anchored securely to a solid surface. Access to stored medication and medication cabinet keys must be limited to school personnel authorized to administer medications. Controlled substances need to be double locked. Each medication should be stored in the original pharmacy label-or manufacturer labeled container with the student’s name on it.

Medication requiring refrigeration should be stored in a locked refrigerator or in a locked container in the refrigerator specifically for medications and not with food. Medication should be stored in locked refrigerators per the temperature specifications of the manufacturer, and the refrigerator temperature should be monitored on a regular basis.

Medications should not be stored in individual classrooms unless all the above standards can be met and the individuals responsible for administration have been properly trained.

It should be made clear in advance where emergency medications such as rescue inhalers, Diastat™, nasal seizure rescue medications, epinephrine auto injectors, and Glucagon™ or Baqsimi™ are stored and who is responsible for supplying or administering them. District procedures should specify how emergency medications will be accessible to staff or students who might need them but are inaccessible to others.

Expiration dates should be checked, medications disposed of upon expiration, and parents/legal guardians notified. Minnesota Statutes § Chapter 121A.22 Subd. 4a. Unclaimed drugs or medications provides specific guidance for medication disposal for prescribed medications and OTCs and controlled substances. Some schools have found it helpful to work with local law enforcement (city or county) in their medication disposal procedure.

Needles and syringes should be disposed of in a manner consistent with the following guidelines from Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens and Needlestick Prevention. Needles should not be recapped and should not be purposely bent or broken. Disposable syringes and needles (and other sharp items) should be placed in approved sharps containers and labeled “biohazard”. Custodial staff or other staff must be given directions for disposing of containers according to established procedures for regulated medical waste.

Each school district medication administration policy and/or procedures should address medication administration on field trips for routine and emergency medications. Parents/legal guardians may choose, but are not required, to accompany their students and administer medications or perform specialized care procedures. Field Trip Preparedness provides information on overall field trip preparedness. The National Association of School Nurses (NASN) has developed a Toolkit for Medication Administration in Schools which provides a Model Procedure for School Sponsored Events and Medication Administration Field Trip Preparation Checklist.

The RN/LSN has the nursing authority to delegate medication administration to unlicensed assistive personnel (UAP) and/or assign medication administration to an LPN. Nursing Delegation in the School Setting provides comprehensive information, standards in delegation and applicable statutes. When the RN/LSN delegates medication administration to a UAP, that UAP must administer the medication and cannot re-delegate that medication administration to someone else unless the RN/LSN is involved in the decision and supervision.

While school administers can assign staff to attend a field trip, only the RN/LSN can delegate the medication administration. In schools without a RN/LSN a school administer assigns staff to administer medications following the procedures which were developed in consultation with a RN/LSN or health care provider.

Volunteers

The use of volunteers to administer medications to students on field trips is no longer a best practice recommendation as was stated in the 2015 Medication Administration Guide because of the complexity of student health concerns and corresponding medications, the student’s right to privacy and possible liability risk for providing health services. Volunteers are best utilized for other tasks on field trips such as providing general supervision and safety for students. It is best practice that school staff be responsible for medication administration through nursing delegation as appropriate.

Preparing Medications for a Field Trip

There are 2 best practice standards for preparing a medication to be administered on a field trip. Preparing medications for a field trip, especially single dose oral medication is a potential safety risk, therefore medication preparation should be completed without distraction or urgency and using the Six Rights of Medication Administration as a guide. The school procedure should clearly define which option will be used and how medications will be checked out for the field trip and checked back in to the health office after returning.

Option One: Request a separate pharmacy labeled container for that oral medication.

• The RN/LSN can put the medication needed only for the field trip into that pharmacy labeled container.
• The RN/LSN may put the pharmacy labeled container with the medication into a secure plastic bag/container. Label the bag/container with the student’s name, and the time the medication is to be given and any other information to ensure safe medication administration following the Six Rights of Medication Administration.
• The school staff member responsible to administer the medication, signs the label with time the medication was given to the student.
• The school staff member returns the plastic bag/container to the school health office.
• This option may be useful for any trips that exceed one day in length.

Option Two: Prepare the oral medication in a medication envelope or other container as appropriate.

• The RN/LSN can puts the medication needed only for the field trip into a secure medication envelope or container. A container may hold only one medication.
• The RN/LSN labels the envelope or container. The label must include the date, the student’s name, the school, the name of the medication, its strength, dose, and time the medication is to be given, any other information to ensure safe medication administration following the Six Rights of Medication Administration and the initials of the person preparing the medication and label.
• The RN/LSN seals the medication envelope or container to prevent loss or tampering.
• The school staff member responsible to administer the medication, signs the label with time the medication was given to the student.
• The school staff member returns the medication envelope or container to the school health office.

In schools without a RN/LSN a school administer should following the procedure which was developed in consultation with a RN/LSN or health care provider.

Emergency medications

Access to emergency medications is a high priority. Emergencies may include conditions such as: anaphylaxis due to life threatening allergy, low or high blood sugar due to diabetes, seizures, and asthma episodes. A copy of the student’s Emergency Care Plan (ECP) completed by the licensed health care provider, must accompany the student along with the medication on the field trip.

Emergency Medication Preparation

• The RN/LSN puts the ECP and medication in a secure plastic bag or container as appropriate.
• The RN/LSN labels the bag/container. The label on the container must include the date, the student’s name, the school, the name of the medication, noting that the ECP is included and the initials of the person preparing the medication and label.
• The RN/LSN seals the bag/container to prevent loss or tampering.
• The RN/LSN using delegation principles trains staff to understand and interpret the ECP, administer the medication, and appropriate follow up. Some emergency responses may include calling 911, the parent/guardian and RN/LSN.
• The school staff member responsible to administer the medication, signs the label with time the medication was given to the student.
• The school staff member returns the plastic bag/container to the school health office.

After any field trip

• The school staff member returns the plastic bag/container to the school health office and confirms if the medication was administered.
• If the student’s medication administration was documented on the medication envelope/label, transfer all information from the field trip prescribed medication envelope label to the student’s medication administration records.
• If the medication administration was completed by a school staff member other than regular school health services staff member, the nurse should place their initials after that person’s name and initials (Jane Doe/J.D.-C.S. RN) and keep the field trip medication envelope on file until the end of the school year.
• If a medication was not given as it is ordered, the designated personnel assigned to that task is responsible. That designated personnel must complete a Medication Error form per the school medication error procedure, including communication to parent/guardian.

Those students who are permitted to self-carry/self-administer their medication during the school day, should be allowed to do so on the field trip. The RN/LSN should encourage the student to self-identify to the school staff supervising the field trip that they have their medication with them. The RN/LSN may need to follow up with the staff supervising the trip and provide additional instructions as appropriate.

Student Self-Administration

There are three statutes that pertain to student carrying and self-administering medication. Minnesota Statutes § Chapter 121A.22:

• “prescription asthma or reactive airway disease medications self-administered by a pupil with an asthma inhaler, consistent with section 121A.221, if the district has received a written authorization from the pupil's parent permitting the pupil to self-administer the medication, the inhaler is properly labeled for that student, and the parent has not requested school personnel to administer the medication to the pupil. The parent must submit written authorization for the pupil to self-administer the medication each school year.”
• “epinephrine auto-injectors, consistent with section 121A.2205, if the parent and prescribing medical professional annually inform the pupil's school in writing that (i) the pupil may possess the epinephrine or (ii) the pupil is unable to possess the epinephrine and requires immediate access to epinephrine auto-injectors that the parent provides properly labeled to the school for the pupil as needed.”

Minnesota Statutes § Chapter 121A.222:

• “A secondary student may possess and use nonprescription pain relief in a manner consistent with the labeling if the district has received a written authorization from the student's parent or guardian permitting the student to self-administer the medication. The parent or guardian must submit written authorization for the student to self-administer the medication each school year. The district may revoke a student's privilege to possess and use nonprescription pain relievers if the district determines that the student is abusing the privilege. This section does not apply to the possession or use of any drug or product containing ephedrine or pseudoephedrine as its sole active ingredient or as one of its active ingredients.”

The National Association of School Nurses (NASN) has developed a Toolkit for Medication Administration in Schools which provides a Model Policy for Self-Carry, Self-Administer Medications, and Contract for Student Self-Carry and Self-Administration of Medication which can be helpful for schools in developing their procedure.

An authorization form completed and renewed annually by the parent/legal guardian and physician licensed health care prescriber and on file in the school will allow a student to responsibly carry medications for self-administration. This authorization is renewed each school year.

Documentation from the prescriber should include the following:

• Verify that the student is capable of and has received training on administering the prescribed medication.
• Name and purpose of the medication
• Prescribed dosage of the medication and route of medication
• Times at which or circumstances under which the medication can be used.
• Duration of time the student can self-administer.

The RN/LSN, parent/guardian and licensed prescribe work collaboratively to ensure the student is capable and reliable to self-carry and self-administer medications and develop a plan to meet the student’s health needs. It may be appropriate for the parent to provide the school with a back-up supply of the student’s emergency medications that they are authorized to self-carry and self-administer.

The LSN/RN, in consultation with the parent/legal guardian and physician/licensed health care prescriber, needs to evaluate the student’s health status and abilities for safe self-administration of prescription and non-prescription medications, observe the student’s first self-administration at school if possible, and communicate regularly with the parent/legal guardian about any medication administration difficulties or successes. Two ways for an LSN/RN to assess student competence are to have the student come to the health office to self-administer, where the LSN/RN can periodically observe the procedure, or by written documentation from a licensed prescriber stating that the student is administering appropriately. The student is responsible to keep track when medications are taken. The student should be instructed to come to the health office at any time if help is needed or questions arise.

District’s policy and procedure should determine if students will be allowed to self-carry or self-administer a controlled substance medication. While there is no statute addressing controlled substances, it is recommended that they not be considered for self-carry self-administration. At a minimum each request should be evaluated on a case by case basis. There must be specific plan made for keeping the student as independent as possible but in compliance with drug laws and safe storage. (e.g., medications could be self-administered, but stored in the health office).

When students are self-carrying and self-administering medications, the student teaching team and other appropriate staff can be informed on a need-to-know basis for legitimate educational interests, as specified by FERPA. The student and his or her parent/legal guardian are informed of how and to whom this information is shared. If there are difficulties with the student’s ability to safely self- administer, including medication security issues, the building administrator discusses with the student and parent/legal guardian the possible discontinuance of the student’s self-administration. This privilege can also be discontinued if medications are shared with other students or not taken as authorized by parents/legal guardians.

Over-the-Counter Pain Relievers

The FDA states there are two categories of over- the-counter (OTC) pain reliever/fever reducers: acetaminophen and nonsteroidal anti-inflammatory drugs (NSAID).

Acetaminophen is used to relieve headaches, muscle aches and fever. It is also found in many other medicines, such as cough syrup and cold and sinus medicines. OTC NSAIDs are used to help relieve pain and reduce fever. NSAIDs include aspirin, naproxen, ketoprofen and ibuprofen, and are also found in many medicines taken for colds, sinus pressure and allergies.

Request for self-carrying or self-administration should not be granted if the dosage exceeds the recommendations on the manufacturer’s label. A licensed prescriber may authorize off-label medication dosages.

Student self- administration agreement

It is recommended that school districts develop a self-carry, self-administration agreement. This should be updated annually or if the medication or dosage changes.

If the medication is prescribed medication, the RN/LSN can use that order as the foundation to build a student contract along with parent authorization. The contract could be part of the student’s individual health plan. The RN/LSN discuss with the student how often and when the student should check-in with the nurse.

Key components of an agreement include:

• The student understands and demonstrates appropriate self-management skills.
• The student agrees to follow instructions and all relevant school policies.
• The student agrees to safely store medication and never allow anyone else access to their medication, even it seems to be an emergency.

If a medication error occurs, districts are best protected from liability when policies and procedures are established collaboratively with input from school nursing personnel, district administrators, and parents/legal guardians.

Medication errors include any failure to administer a medication as prescribed for a particular student and may include not administering to the right student, at the right time, the right medicine, the right dose, by the right route, or with the right documentation.

The district must develop a medication error procedure for reporting, documenting, informing and then evaluating. It is important to establish a culture of safety. Category of errors include simple human error, at-risk behavior, reckless behavior, but most often these are system failures whereby the organization did not have adequate procedures, inadequate training, high workloads, and unrealistic time expectations. There should be a fair and just culture for reporting errors as a quality improvement process and providing emotional safety to those who may make an error.

If an error in medication administration occurs, the following steps should be initiated:

• Identify the nature of the error.
  • Wrong dose
  • Wrong medication
  • Missed dose
  • Wrong person
  • Wrong time
  • Wrong route
• Keep the student in the health office. If the student has already returned to class when the error is determined, have the student accompanied to the health office.
• Monitor the student’s behavior and physical symptoms. If the student’s symptoms are life- threatening, call 911 prior to calling parents.
• Notify parents/legal guardians, supervising LSN/RN, principal/designee, and student’s physician.
• If unable to contact the physician or licensed prescriber, contact the Poison Control Center for instructions. Give the name and dose of the medication given in error; the age and approximate weight of the student; and the name, dose, other medications being taken by the student, and time of last dose of other medication, if possible.
• Carefully record in the student’s health record all circumstances and actions taken.
• Submit an occurrence report to the principal or program administrator within 24 hours. Include the name of the student, the parent/legal guardian’s name and phone number, and a specific statement of what the medication error was, who was notified, and what remedial actions were taken.
• Review the error and determine what factors contributed to the error.
  • Communication
  • Lack of Knowledge or training
  • Distraction in the environment
  • Equipment
  • Emergency situations
  • Other

Reducing Errors and Omissions

The RN/LSN or designated school health personnel should review reports of medication errors, analyze patterns, and take necessary steps to avoid future problems. The purpose of monitoring medication errors is for system correction rather than individual blame. Eliminating distractions and/or other responsibilities during periods of concentrated medication administration can increase safety and decrease the potential for errors. School administration and/or the LSN/RN should review medication error reports and take steps to develop a correction plan to avoid future problems.

Refusal to Take Medication

While not technically an error, if student medication refusal is not addressed timely and appropriately it could be considered a medication error.

Schools should have consistent policies to address handling situations with students who do not appear or who refuse to take ordered medications. It is best to address these situations on an individual basis depending upon what the medication is and how often the student fails to take the medication. If a medication is not given, policies should address the extent to which school personnel will attempt to administer the medication, as well as procedures for notifying a parent/legal guardian and licensed prescriber and completing an occurrence report.

Health services staff should monitor student noncompliance with medication administration. Action or issues of medication administration refusal or noncompliance should be reported by the LSN/RN or designated school health personnel to the licensed prescriber, parent/legal guardian, and student.