Guidelines for the Administration of Medication in School
- Committee on School Health
Many children who take medications require them during the school day. This policy statement is designed to guide prescribing physicians as well as school administrators and health staff on the administration of medications to children at school. The statement addresses over-the-counter products, herbal medications, experimental drugs that are administered as part of a clinical trial, emergency medications, and principles of student safety.
School districts are required to provide medication at school. Many children and adolescents with special health care needs are able to attend school because of the effectiveness of their medication. Many of these children would otherwise be educated at home or in special schools. The health circumstances that require medication are diverse. Pharmaceutical innovations and new technologies to deliver them have enabled most medication-dependent students to be mainstreamed into classes with their peers.
Section 504 of the Rehabilitation Act provides protection for students with disabilities by requiring schools to make reasonable accommodations and to allow for safe inclusion in school programs.1 This federal law applies only to schools receiving federal funds, does not cover all students who require medications during the school day (eg, short-term needs), and is not specific about how administration of medications should be conducted in school. Some states have laws or standards that establish more specific policies for administration of medications that apply to all of the state’s school districts.2 This prevents significant discrepancies among school districts within the state and reduces confusion for parents of medicated children and prescribing health care professionals. Nevertheless, it remains the responsibility of school boards and school superintendents to honor policies and establish mechanisms for the administration of medication in the school setting. When state laws or guidelines do not exist, school health professionals, consulting physicians, and medical advisory committees should be involved in this process. Individual school districts also may wish to seek legal advice as they assume the responsibility for giving medication during school hours.3 Liability coverage should be provided for the staff, including nurses, teachers, athletic staff, principals, superintendents, and members of the school board. Any student who must take medication during regular school hours should do so in compliance with all federal, state, and district regulations.
The American Academy of Pediatrics recommends that school districts consider the following medication issues when writing policy.
PARENT-RECOMMENDED SHORT-TERM MEDICATIONS
School administrators and health personnel should consider whether the administration of over-the-counter, parent-recommended medications is worth the problems that this practice presents. Benefits of pain relievers, anti-inflammatory medications, and antihistamines, for example, are that there may be symptomatic improvement for the student that enables learning and causes less classroom disruption. However, disadvantages include difficulty in obtaining physician permission for such limited use, liability of the school district in assisting with the administration of an unprescribed medication that has potential to cause harm, and issues of school safety and security of drug use (eg, sharing of medication between classmates). The social realities of parents who work, often in jobs that do not allow for medical leave to attend to their children’s illnesses, may require that they send their children to school with mild illnesses. Because of these realities, it may be necessary to consider allowing the administration of parent-recommended medications for students during the school day on a short-term basis.
EMERGENCY AND URGENT MEDICATIONS
Emergency medications are often given by nonoral routes. Some require training to administer. Some medications, such as epinephrine injections for severe allergic reactions or glucagon for hypoglycemia (low blood sugar), have few significant adverse effects. Because these episodes, by nature, occur at unpredictable times when a school nurse may not be available, trained designated school staff should be available. Some emergency medications require more medical training because of the complexity of administering them or because of adverse reactions that may occur as a result of their administration.4 Emergency use of oxygen is one example. In these cases, the availability of a school nurse on site must be considered.
Urgent medications are given to children who experience sudden pain or fever (eg, headaches, toothaches, menstrual cramps). Some schools keep a small stock of acetaminophen, ibuprofen, or antihistamine to cover sudden circumstances. It is important that parent permission be provided to allow the school health staff to dispense these medications and that this permission encompass the whole school year.
SECURITY AND STORAGE OF MEDICATION
All prescription medications brought to school should be in a container appropriately labeled by the pharmacist or the physician. All over-the-counter medications should be in their original containers and returned to the parents at the end of the school year or disposed of according to existing laws.
A student may be permitted to carry medication when the medication does not require refrigeration or security according to policies determined by the school. School personnel must also grant permission for the student to take the medication. The student must be capable of self-administration and responsible behavior. Some schools have given a “medication pass” to students, verifying school permission for the student to carry and take medication.
The accessibility of some medications may be crucial to the success of their effectiveness. Prepared syringes of epinephrine for treating serious allergic reactions are an example. Answers to questions, such as where the medication will be stored, who is responsible for the medication, and who will carry the medication for field trips, should be defined in advance to maintain medication security and safety while ensuring timely treatment.
PRINCIPLES OF STUDENT SAFETY
To provide for the best possible medical outcome, schools need to develop protocols to prevent medication error. This should focus on a systems approach that ensures the safe keeping and delivery of medication in a timely fashion. It is appropriate to develop a system of accountability for students who carry and self-administer their medications.
The leadership in developing safe guidelines lies with the certified school nurse, the physician, and the parent.5,6 Training and education of faculty and parents will help prevent errors in dosing and usage. When school nurses delegate care to nonmedical staff members, a system should be devised through which the school nurse, parent, and physician are comfortable with the protocol.7
GUIDELINES FOR PEDIATRICIANS
Pediatricians, other child health professionals, and their state-level professional organizations should work with state departments of health and/or education and with local schools and districts to support the development of sound medication policies.8
Physicians should be aware that prescribing drugs on an “as-needed” basis can be problematic in schools where no health professional is available at the school site to assess the actual need. Any medication that can be given on a regular basis rather than “as needed” should be prescribed as such to avoid giving school staff members and the student responsibility to determine the need.
The prescribing pediatrician or other health professional should notify the school (usually on school medication forms) of adverse effects that may be reasonably expected and contraindications to administering the medication.
School districts and their personnel are not obliged to administer experimental medications and medication doses that exceed dosages approved by the US Food and Drug Administration. Prescribing physicians should inform schools of the nature of each drug that is administered in school as well as adverse effects that may be expected for each drug that may be part of a blinded experimental trial. The prescribing physician should provide this in a written format for the school, and the packaging at school should include the experimental code.
The physician should state whether a student is qualified and able to self-administer a medication, and this input, along with the consent of the parent, student, and school staff, should be used to determine whether this is advisable.
GUIDELINES FOR ADMINISTRATORS AND HEALTH PERSONNEL IN SCHOOLS AND SCHOOL DISTRICTS
To administer any prescribed medication, require a written statement from the parent and the physician that provides the name of the drug, the dose, approximate time it is to be taken, and the diagnosis or reason the medication is needed. Administration of medications purchased outside the United States is not exempt from requiring the written prescription of a US-licensed physician.
School policies and practices for medication administration must ensure that student confidentiality is protected, as outlined in the Family Education Rights and Privacy Act9–11 and the Health Insurance Portability and Accountability Act.12
In the absence of trained medical staff, the school principal or a designee should administer medication to students. It is imperative that any person administering medication be educated about the method of administration and contraindications to giving the medication. Specify how the medication will be administered to students when they participate in field trips, school camps, and other out-of-school activities.
Older and responsible students should be allowed to self-medicate at school with over-the-counter medications and certain prescription medications (eg, albuterol for asthma, insulin for diabetes) when this is recommended by the parent and physician and the student is deemed responsible to remember prescribed doses. Obtain written notification from parents acknowledging that the school bears no responsibility for ensuring the medication is taken. Immediately confiscate medication shared with classmates and remove the student’s privilege of self-administration.
Herbal medications can have serious and dangerous adverse effects. These and over-the-counter medications, when taken on a regular basis, should require a physician’s note that in essence “prescribes” these nonprescription medications. The school should have physician-approved protocols (indications, dose, and contraindications) for using over-the-counter medications, should never use a drug for children at ages below which the drug is not approved (unless it is prescribed), and should reserve the right to limit the duration that over-the-counter medications are administered solely on the basis of parent recommendation.
Notify parents that it is the parents’ responsibility to supply the school with prescribed medications, provide labeled containers, keep medications current, supply medical devices (eg, nebulizers, insulin pumps, oxygen), and help to maintain these devices.
Protocols for the documentation of all therapies given at school, whether emergency or routine, should be established. Some schools use a log, and others use a computer-based student medical record system. Any errors in medication administration at school need to be reported to at least 1 common supervisor so that patterns of errors and corrective action can be taken. Measures taken by school administrators after a medication error must be designed so that they do not discourage staff self-reporting of errors.13
Committee on School Health, 2002–2003
*Howard L. Taras, MD, Chairperson
Barbara L. Frankowski, MD, MPH
Jane W. McGrath, MD
Cynthia Mears, DO
Robert D. Murray, MD
Thomas L. Young, MD
Janis Hootman, RN
National Association of School Nurses
American School Health Association
Jerald L. Newberry, MEd
National Education Association Health Information Network
Mary Vernon-Smiley, MD, MPH
Centers for Disease Control and Prevention
- Copyright © 2003 by the American Academy of Pediatrics