Procedure 3416P

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Medication At School

Whenever possible prescribed and over-the-counter (OTC) medications shall be administered before and/or after school hours under the supervision of the parent/guardian.

A parent/guardian may administer prescription or OTC medication to his/her child at school.

If there is a valid health reason that requires that a student must receive prescribed or OTC oral medication, topical medication, ear drops, eye drops or nasal spray (“medications”) from an authorized school staff member during school hours,the following procedures must be followed.

Prescription and OTC Medication

Any prescription or OTC medication to be taken by a student at school, on field trips or at co-curricular activities must be registered with the certificated school nurse. OTC medication requires the same medication administration provisions (e.g. written, current, unexpired request from a licensed healthcare provider prescribing within the scope of his/her prescriptive authority (LHCP) and parent/guardian, storage, supply, etc.) as prescription medications. The medication administration statute,RCW 28A.210.260, makes no distinction between prescription and OTC medication.

Medication Authorization

Medication may only be administered to students on a scheduled or as needed basis upon written authorization from a parent/guardian with a written request by LHCP. The written request must be accompanied by written instructions from the LHCP. The authorization is valid for the current school year, including summer school, unless a shorter time period is specified. A current list of health care professionals who are authorized to prescribe and administer medication can be found at:

Although it is preferable to have the medication orders on district forms, as long as the orders contain the essential elements of a valid orderthey can be accepted.

Essential elements of a medication order:

  1. Student name
  2. Medication name
  3. Medication dosage
  4. With delegated medications, the dosage must be finite. Unlicensed personnel cannot make nursing judgments.
  5. E.g. “2-4 puffs” from an inhaler is not acceptable, but “4 puffs” is.
  6. Medication route
  7. Time and indications for medication administration
  8. The valid health reason which makes it advisable that that the medication be administered at school
  9. Side effects to watch for
  10. Date
  11. Signature of parent/guardian
  12. Signature of LCHP

Medication

Parent/guardians shall provide all medications for their child.

  • Prescription medications must be in the original pharmacy-dispensed container, with a label matching the medication ordersandinclude the student’s name. Pharmacies can provide a “school” container for medication.
  • OTC medications must be in the original manufacturer’s container labeled with the student’s name.
  • All medications must be unexpired. It is recommended that the parent/guardian provide medication that does not expire during the school year.

The parent/guardian will only provide enough medication for one month.

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 not possible, the parent/guardian willdivide the dose using their own tablet cutter or single-edge razor. Staff should avoid cutting tablets whenever possible.

Medication Storage

Medications should be stored in a locked or access limited area. Access to medication cabinet/container keys should be limited to staff designated to administer medication. Controlled medication should have the highest level of security. Emergency medications such as inhalers, epinephrine auto-injectors and seizure emergency medications must be readily accessible.

School Staff to Administer to Medication

Registered nurses and licensed practical nurses who are school staff may administer medications as permitted by their license (RCW 18.71 and RCW 18.79) Each school principal, in consultation with the certificated school nurse, will designate two or more staff members to administer medications. The staff member who administers a medication is responsible to document that medication administration.

Training of School Staff in Medication Administration

RCW 18.79.260 and WAC 246-840-010 allow for licensed registered nurses and advanced registered nurse practitioners to delegate the administration of medication to unlicensed staff. Delegation means that the certificated school nurse transfers selected nursing tasks to competent individuals in selected situations. The certificated school nurse delegating the task retains the responsibility and accountability for the nursing care of the student. Designated staff members will participate in an annual in-service training conducted by the certificated school nurse prior to the administration of any medication. The certificated school nurse supervises the performance of the unlicensed staff person with respect to the performance of the delegated task. The certificated school nurse will evaluate the trained staff person’s skill and document the successful completion of the training.

Additional guidance on delegation in schools is available with the Nursing Commission’s Scope of Practice Decision Tree; and the Office of the Superintendent of Public Instructions’ Staff Model for the Delivery of School Health Services (page 4 and 5).

Medication administration training is to cover:

  • Washington State law and school board policies governing the administration of medications
  • Required medication administration documentation
  • Procedures to follow in administering medication, including when not to administer a medication
  • Procedures to follow in the event of a medication error, missed dose or delayed dose
  • When to contact the supervising school nurse
  • Confidentiality issues regarding medication administration and student health information

Medication Routes

Registered nurses may delegate the administration of oral medications, topical medications, ear drops, eye drops or nasal spray to unlicensed staff. (RCW 28A.210) Oral medications are administered by mouth either by swallowing, absorption through the oral mucosa or by inhaling and may include administration by mask if the mask covers the mouth or mouth and nose. (Per Washington State Nursing Care Quality Assurance Commission Practice Committee, 9/8/00).

Medication Dosage Changes

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

  • The verbal order must be followed by a written order in a reasonable amount of time.
  • Faxed orders are considered written orders. The certified school nurse must be confident that the fax came from the ordering LHCP.
  • Prescription container with the old order can be used for up to ten school days to give the parent/guardian time to get a container with the current order, as long as the certificated school nurse has a current order, directs the designated, trained school staff to use the available container, and the medication provided is consistent with the dosage ordered.

All new LHCP requests or orders for medication should be approved by the certificated school nurse prior to the administration of the first dose. This is a “best practice” guideline.

Discontinuance of Administration of Medication

A parent/guardian can discontinue medication administration at school at any time by notifying the certificated school nurse orprincipal by written note, email, telephone call or message, or by fax.

A school can discontinue medication administration if the following conditions are met:

  • The superintendent of the school district or 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.

Emergency Injection Medications

Administration of emergency medications by injection is covered by WAC 246-840-070(7) (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 a registered nurse of unlicensed school staff is recommended for administration of a pre-dosed epinephrine auto-injector device to prevent anaphylactic shock in students with known sensitivity to specific allergens (e.g. bee stings, foods, latex, etc.) or as prescribed by the LHCP.

  • No prescribed medication shall be administered by injection by unlicensed staff except when a student is susceptible to a pre-determined, life-endangering situation.
  • Parent/guardian supplies a current and unexpired request that includes the name of the student, a signed LHCP order and signed parent/guardian permission that grants a staff member the authority to act according to the specific written orders and supporting directions provided by the LHCP.
  • The authorization form indicates the identity of the drug, the medication route, the medication dose, the sensitive allergen, indications for epinephrine administration including when the injection will be administered based on anticipated symptoms or time lapse from exposure to the allergen, administration of additional medications and follow-up measures.
  • Parent/guardian supplies the emergency medication.
  • Parent/guardian and the LHCP are to be notified of any emergency treatment actions.
  • A trained, unlicensed staff person is to be designated by the certificated school nurse to have the responsibility for carrying emergency medications when students leave school premises and are under the supervision of school staff during the regular school day.
  • Emergency medication is to be stored in a secure, yet quickly accessible, location.
  • The medication expiration date is to be monitored by the certificated school nurse. Parents/guardians are encouraged to provide medication that will not expire during the school year.
  • It is the responsibility of the parent/guardian to keep the school informed of changes in the student’s condition or changes in LHCP orders. They must keep emergency contact information current.
  • If a LHCP determines that the student no longer has a life-threatening condition that requires emergency medication at school, the LHCP must inform the school of this in writing.
  • Record keeping: The staff person who administers the medication has the responsibility to document this activity.
  • The certificated school nurse much be consulted prior to accepting any injectable medication.

Nasal Spray Medications that are Legend Drugs (Prescribed) or Controlled Substances

RCW 28A.210.260directs that “if a school nurse is on the premises, a nasal spray that is a legend drug or a controlled substance must be administered by the school nurse. If no school nurse is on the premises, a nasal spray that is a legend drug or controlled substance may be administered by a trained school staff member. After a school employee who is not a school nurse administers a nasal spray that is a legend drug or a controlled substance, the employee shall summon emergency medical assistance as soon as practicable.”

  • School nurse means a certificated school nurse or other licensed nurse who is a staff member.
  • A staff member trained by the certificated school nurse to administer nasal spray has volunteered for the training pursuant to RCW 28A.210.260.
  • “Legend drugs” means any drugs which are required by state law or regulation of the pharmacy quality assurance commission to be dispensed on prescription only or are restricted to use by practitioners only. RCW 69.41.010 (12)
  • See the link in the controlled substances section to determine if a drug is a controlled substance.

Intranasal Seizure Emergency Medications

  • Directions about how to administer intranasal seizure emergency medication will be kept with the medication.
  • The frequency of intranasal seizure emergency medication training for unlicensed staff will be at least annually and may be more frequent according to the severity of the student’s condition at the determination of the certificated school nurse.
  • Every effort will be made to delegate to staff members who work routinely and regularly with the impacted student.

Narcotic Pain Medication

In general, administration of narcotic pain medication at school is not appropriate. Individual cases may be considered in consultation with the certificated school nurse, school principal, LHCP and parent/guardian. Consideration is given to the student’s medical diagnosis, whether it is acute versus chronic pain and the medication in question. If it is determined that the student should receive narcotic pain medication at school, the district policy and procedure is to be followed regarding administration and authorization of the medication. As controlled substances must be kept locked, narcotics are not to be carried and self-administered by students. Any variations from the narcotic pain medication provisions listed in these procedures are to be determined by the professional judgment of the certificated school nurse and documented.

Medical Marijuana

RCW 69.51A.060 (4) states “Nothing in this chapter requires any accommodation of any on-site medical use of cannabis in any place of employment, in any school bus or on any school grounds, in any youth center, in any correctional facility, or smoking cannabis in any public place or hotel or motel.”

Delayed Start Provisions

Staff should make plans with parent/guardians and LHCPs regarding medication administration and the timing of the administration on delayed start days.

Receiving Medication at School/Medication Inventory

It is strongly recommended that the parent/guardian bring medication to school. All medication received by school staff is to be immediately counted (number of pills, volume of medication, number of delivery devises, etc.) and documented by school staff and parent/guardian or designated adult when brought to school.

End of Year Medication Procedures

Parents/guardians will be notified in writing of the need to pick up medication and the date of medication disposal if medication is not picked up. It is strongly advised that the parent/guardian or designated authorized adult pick up medication from school. When an undue hardship prevents an authorized adult from picking up medication, the student may transport medication from school when it is deemed appropriate to do so safely; the certificated school nurse or principal makes this determination considering the developmental capacity of the student as well as the potential risk for abuse or misuse of the medication. Parents/guardians will be provided with medication administration forms for the next school year.

Medication Disposal/Medication Inventory

Prior to disposing of unwanted or left over medication, the medication will be counted by two school district staff.The date,staff namesand medication quantity will be documented.

Medication waste should be brought to KEC - Health Services for disposal.

  • Leave medication in original packaging (bottles, tubes, foil pouches, blister packs)
  • Liquids must be tightly capped and placed in a sealed plastic bag
  • Loose pills must be in a container
  • No controlled substances
  • No mercury thermometers or other devices containing mercury
  • No sharps (except activated epinephrine auto-injectors)

Used Epinephrine Auto-injectors

  • Epi auto-injectors used on students should be given to EMS and transported to the hospital with the student so the Emergency Department knows exactly what was administered.
  • Epi auto-injectors which did not go to the hospital with a student or were used for training staff, can NOT go in the sharps container.
  • They need to go in a pharmaceutical disposal container at KEC - Health Services.
  • When transporting the activated epi-auto injectors to KEC to go in the pharmaceutical disposal container, contain them in a sealed box or other similar container and ideally transport them in the trunk (and not in the passenger compartment of the vehicle.)

Diabetes Test Strips

Diabetes test strips can go in the regular garbage. They do not need to go in a sharps container.

Controlled Substances

See for a current list of controlled substances. Contact the Safety and Security Manager to coordinate a pick-up of controlled substances for disposal.

Mercury Containing Items

Items containing mercury must NOT be disposed of in a sharps container or with pharmaceutical waste or controlled substances. Contact Health Services for instructions about disposal of mercury thermometers.

Sharps Disposal

School sharps containers are for sharps generated by students in the school setting. Sharps containers will be picked up from school clinics by the district-contracted sharps disposal company. When a sharps container reaches the “fill line”, call Health Services to arrange pick up.

Sharps includes:

  • Hypodermic needles
  • Syringes with needles attached
  • Lancets that have been removed from original packaging

Medication Theft

Theft of any medication should be documented and reported to the certificated school nurse, the Director of Health Services, the school principal, the District Security Manager and the parent/guardian. A report to local law enforcement may be indicated, particularly if the theft involved a large quantity of medication.

Counting of controlled substances periodically is recommended by the Board of Pharmacy according Administration of Medications in Schools Bulletin No. 34-01 Learning and Teaching Support.

Medication Errors

The correct medication must be administered to the correct student at the correct time, in the dosage prescribed, by the correct route and includes correct documentation of the medication administration as ordered by the LHCP and requested by the parent/guardian. Deviation from this standard is a medication error. A dose that is missed (omitted) may also be considered a medication error.

It is not considered a medication error when a student misses a dose of medication:

  • When it is documented that the student did not report for medication administration after one attempt has been made to contact the student to come for medication administration and/or
  • When it is documented that the student did not respond or refused to comply with the request to come or to take the medication.

Best practice guideline is to notify the certificated school nurse and parent/guardian of the situation when possible and to document this communication. This is a compliance issue.

Parent/guardians will agree in writing that, because of the school schedule and other potential circumstances, it is permissible for a dosage or dosages of medication to be delayed or missed. If the parent/guardian refuses to accept that condition, the district will reject the request to administer medication at school.

All medication errors must be documented on the Medication Error Report, Form 3647, and reported to the certificated school nurse who provides supervision for school staff giving the medications and the Director of Health Services. (RCW 28A.210.260 and 270 and DOH advisory, May 2001)