Dr. Terry Bergeson, State Superintendent of Public Instruction

Transcription

1 June 8, 2001 ( ) Action Required (X) Informational BULLETIN NO LEARNING AND TEACHING SUPPORT TO: FROM: RE: Educational Service District Superintendents Chief School District Administrators Private School Chief Administrators School Nurse Supervisors ESD School Nurse Corps Supervisors Dr. Terry Bergeson, State Superintendent of Public Instruction The Administration of Medications in Schools I. Introduction The purpose of this bulletin is to review the requirements of RCW 28A and 270 (Public and private schools Administration of oral medication) and to address ancillary issues and frequently asked questions. We will also discuss guidance material (Section VI) from the Nursing Care Quality Assurance Commission regarding the reporting of medication errors in schools. This bulletin will address the following: (Section II) The Oral Medication Statute (pages 2 5) General Provisions Over-the-Counter Medications Inhaled Medications Medication by Routes Other Than Oral (Section III) Student Self-Administration of Medication (pages 5 6) (Section IV) Emergency Medications (pages 6 7) (Section V) Training of School Staff in the Administration of Medications (page 8) (Section VI) Nursing Practice and Board of Pharmacy Issues and Recommendations (pages 9 14) Health Care Providers Who May Prescribe Security of Controlled Medications Oral Medication Error Reporting in Schools

2 BULLETIN NO LATS Page 2 June 8, 2001 (Section VII) Field Trips and Medication Administration (pages 14 15) (Section VIII) Disaster Planning/Medications (page 15) (Section IX) Record Retention Requirements (page 16) Where statutes and regulations apply, they are cited by number. In all other instances, best practice and good nursing care are recommended. II. Oral Medication Statute (RCW 28A and 270) General Provisions This law (Attachment A) authorizes public school districts and private schools to implement policies and procedures whereby students may receive oral medications, prescription as well as over-the-counter (OTC) medications, at school. Certain very specific conditions must be in place. The law provides that when the conditions specified in statute and written instructions from a licensed health professional (LHP) prescribing within the scope of his or her prescriptive authority are substantially complied with, then the employee, the school district or school, and the members of the governing board shall not be liable in any criminal action or for civil damages as a result of the administration of the medication. The following is an outline of the statutory conditions: A. Each school board shall seek advice from at least one licensed physician or nurse in the process of developing its policies. See Attachment B for a policy developed by WSSDA (Policy No. 3416). B. Each school board shall adopt policies which address: 1. Designation of employees who may administer the medication. 2. Acquisition of parent requests and instructions. a. Such requests must be in written form and must be current and unexpired. b. The request must be from a parent, legal guardian, or other person having legal control over the student. 3. Acquisition of the LHP requests and instructions. See Attachment B for an example of a form meeting statute requirements. a. The request must be in written form and must be current and unexpired.

3 BULLETIN NO LATS Page 3 June 8, 2001 b. The request must be from a LHP prescribing within the scope of his or her prescriptive authority for administration of the medication. c. The request must state that there exists a valid health reason which makes administration of the medication advisable during school hours or during such time that the student is under the supervision of school officials. The request is not the prescription nor will the bottle label meet the statutory requirement for a request from a LHP. 4. Additionally, written, current, and unexpired instructions must be obtained from the LHP regarding the administration of prescribed medication to students who require medication for more than 15 consecutive days. Please note that the statute requires a request from the LHP no matter how long the medication is to be taken, but requires instructions from the LHP only if the medication is to be taken for more than 15 consecutive working days. C. The identification of the medication to be administered (See E.3., this page) and the means of safekeeping medication (page 11) with special attention given to the safeguarding of legend drugs. D. The means of maintaining a record of the administration of such medication. (See Section V, page 8.) E. Administration of the medication: 1. The medication must be administered by a district employee designated by or pursuant to the district s policy. 2. The medication, whether prescription or over the counter (OTC), must be administered in substantial compliance with the prescription or written instructions of the LHP. See discussion of OTC medications on page 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. 4. The designated staff person shall be trained and supervised in proper medication administration by a licensed professional person, pursuant to chapter RCW (Physicians [MD]) or chapter RCW (Nursing Care).

4 BULLETIN NO LATS Page 4 June 8, 2001 F. Discontinuance of administration of medication 1. 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. 2. Such notice shall be made to the parent, legal guardian, or other person having legal control over the student. Please note that though the statute uses permissive language for implementation and discontinuance, requirements for Section 504 of the Rehabilitation Act of 1973 may apply to the administration of oral medications during the school day for students with disabilities. Further, there must be a valid reason, one which does not compromise the health of the student, to discontinue medication administration at school for any student. Over the Counter Medication (OTC) The statute makes no distinction between prescription and non-prescription medication. The Office of Superintendent of Public Instruction (OSPI) has interpreted the statute to include OTC medications. Although schools may administer medications obtained without a LHP s prescription, they may do so only on a LHP s request. In other words, simply because a school administers an OTC medication rather than a prescription medication does not relieve the school from the obligation to get a written, current, and unexpired request from a LHP prescribing within the scope of his or her prescriptive authority for the administration of that medication (RCW 28A [4]). Failure to get a LHP s request may exclude the school from the protection of RCW 28A (1), which states that schools and their employees shall not be liable in any criminal action or for civil damages... if they comply substantially with RCW 28A Inhaled Medication The state law allows administration of oral medications by designated school personnel. The statute addresses oral medications only. Medications administered by other routes (ointments, injections) are not covered under this statute. The Washington State Nursing Care Quality Assurance Commission, Practice Committee in a September 8, 2000, advisory opinion provides the following guidance regarding inhaled medication: May an RN in a school setting delegate to an unlicensed school employee, the following task(s) related to the care of children with asthma?

5 BULLETIN NO LATS Page 5 June 8, 2001 Assist a student who uses a mask or Aerochamber-style spacer for inhaled medication for asthma the medication is ordered by mouth, but the device also covers the nose: Response: Yes, if the medication is ordered for oral inhalation, it falls within the category of po or by mouth whether or not the mask or spacer covers the mouth or the mouth and the nose. Medications ordered to be administered intranasally are not included within this category. See Attachment C for the full text of the opinion. Medications by Routes Other than Oral The statute addresses oral medications only. Medications administered by other routes (ointments, injections) are not covered under this statute. Medications given by routes other than the oral route are considered nursing care and regulated by the law relating to nursing care, RCW. Medications such as ointments, eye or ear drops, suppositories, or injections that are ordered by a LHP can only be administered by student family members, registered nurses (RNs) or licensed practical nurses (LPNs), or self-administered by the student. The administration of medications by routes other than by mouth cannot be delegated to unlicensed school staff except in an emergency situation. (See Section IV, pages 6 7.) III. Student Self-Administration of Medication There are instances in which a LHP and parent may request that a student be permitted to carry his/her own medication and/or to self-administer the medication. Self-administration of medication is not within the purview of the statute which addresses non-nurse school district staff administering oral medications to students. Given no statutory or regulatory guidance on this issue, the issue falls under school district policy. In developing policy on the self-administration of medication, the WSSDA policy is very useful. (See Attachment B.) We suggest school districts may want to consider several adaptations to the WSSDA model policy that would address who approves the student self-administration, and consideration of the developmental/grade level of students permitted to self-administer medications. The district may want to consider developing two different lists of individuals who must approve of students carrying their own medications: an approval list for prescription medications and a second approval list for OTC medications. For OTC medications, you may require building principal, parent, and school nurse approval for self-administration.

6 BULLETIN NO LATS Page 6 June 8, 2001 For prescription medications, approval of building principal, LHP, school nurse, and parent may be appropriate. The district may want to consider permitting students at certain grade levels or developmental level to carry their own medication, prescription and/or OTC, e.g., high school students only. These determinations are within the purview of school boards and district administration because no statute governs self-administration of medication. We strongly recommend that the school nurse be involved in the development of all district policies on medication administration. IV. Emergency Medications Emergency medications administered by injection are addressed in the rules and regulations governing the practice of the registered nurse. WAC (10)(b) states: "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 [1][b] and [2][b])." We recommend training and supervision by an RN of non-nurse school staff in the administration of epinephrine to prevent anaphylactic shock in students with known sensitivity to bee stings, foods, latex, etc. WSSDA policy 3416, Students, Medication at School states: No medication shall be administered by injection except when a student is susceptible to a predetermined, life-endangering situation. In such an instance, the parent shall submit a written and signed permission statement. Such an authorization shall be supported by signed and dated written orders accompanied by supporting directions from the LHP. A staff member shall be trained prior to injecting a medication. Attachment B. We recommend that the LHP provide specific orders and protocols for the student that include a description of expected symptoms or indicators of when to administer the epinephrine or other drugs and any other first aid measures that might be indicated. In any situation, if a student who has a history of severe reaction to insect bites, stings, latex, food, etc., is exposed to the known allergen and/or develops symptoms of anaphylaxis, call 911 and implement the emergency plan for the student. We recommend that the care plan include: A. Written, signed, current permission from parent or guardian. B. Identification of who may administer the medication and inservice requirements for doing so. Note: Training materials may be available from the manufacturer of automatic injectable medication administration systems.

7 BULLETIN NO LATS Page 7 June 8, 2001 C. Written orders, signed and dated, from the LHP that: 1. States that student suffers from an allergy which may result in an anaphylactic reaction. Identifies the precipitating allergen, if known. 2. Identifies the drug, the mode of administration, and the dose. Epinephrine administered by inhalation, rather than injection, may be a treatment option. This decision is made by the LHP. 3. Indications for administration. 4. Recommendations for follow-up after administration, which may include care of the stinger, need for a tourniquet, administration of additional medications, transport to hospital. 5. Requirements for reporting to the LHP and record keeping recommendations. D. Procedures for notifying of parents of emergency treatment. E. Designation of who has responsibility for carrying the emergency medications when students leave school premises but are under the supervision of school staff. F. Proper storage of the medication and monitoring of expiration date on medication. It is the parent s responsibility to keep school staff informed of changes in the child s condition or changes in LHP orders. They must also keep emergency contact information current. The parent is to supply the medications. Most districts designate that epinephrine be administered by automatic-administration devices. Non-nurse school staff are more comfortable and therefore more likely to use these devices. In addition, the training by the school nurse or other licensed health care provider is less complicated because the trainer does not have to train school staff in the use of syringes. Though the device is designed for selfadministration, most students may be too young or too ill to self-administer the epinephrine and, hence, the necessity to train all school staff who will be monitoring the student's symptoms during the school day in the use of the device.

8 BULLETIN NO LATS Page 8 June 8, 2001 V. Training of School Staff in the Administration of Medications The oral medication statute requires that staff designated by district policy to give medications are to be trained and supervised by a professional person licensed pursuant to chapter RCW (MD) or chapter RCW as it applies to registered nurses and advanced registered nurse practitioners (ARNP). OSPI s recommendation is that prior to the beginning of a new school year, district administration or building principals should identify in writing at least two staff persons per building to administer oral medications for the coming school year. These individuals shall receive training in the following prior to administering medications to students: A. School board policies and procedures governing the administration of oral medications. B. Procedure to follow in administering medication, including description of when not to administer a medication. C. Procedures to follow in the event of a medication error, missed dose, or delayed dose. D. Required charting. E. When to contact the supervising nurse. F. Confidentiality issues regarding the administration of medications and student health information. A copy of a procedure for administering oral medications from Administering Medications to Iowa Students: A Guide, Iowa Department of Education, June 1995, is in Attachment D. The supervising nurse will evaluate the staff person's skill and document the successful completion of the training. The supervising nurse will determine the degree of supervision necessary and provide that supervision. The following contain useful training documents and sample forms: (1) Attachment E, Medication Administration Skills Check List adapted from a form developed by the Marysville School District; (2) Attachment F, Medication Monitoring Check List, adapted from a form developed by the Spokane School District; (3) Attachment G, Medication Log, adapted from a form developed by the Colorado State Board of Nursing; (4) Attachment H #1, Medication Error Report Form, adapted from a form developed by the Missouri Department of Education. In order for the district to receive the immunity from liability based upon substantial compliance with the statute, non-nurse school staff must be trained and supervised by an RN or MD.

9 BULLETIN NO LATS Page 9 June 8, 2001 VI. Nursing Practice and Board of Pharmacy Issues and Recommendations In this section, we will discuss best nursing practice in relation to procedures for the receipt and storage of medications by school staff, inventory control, proper disposal of oral medications, and medication error reporting. Medications that parents ask school district staff to administer should be brought to the building office by the parents, guardian, or designated adult substitute. We make this recommendation because many of the ordered medications are controlled substances. Because of reports of robberies of school buildings to obtain these drugs, reports of students selling these substances, and because of the student safety issue of being a possible robbery target, we recommend that an adult transport medications to school. For medication given for less than 15 days, the properly labeled medication container with name of the medication, student name, date, quantity, strength per dosage unit, licensed health professional name, and how often the medication is to be given; signed parent request; and LHP request are required. For medications given more than 15 days, LHP instructions are required in addition to the above. The authorization request is considered current for the school year unless the prescription is for less time. All medication should be counted by school staff and the parents or 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. (See Attachment I.) The school supply of controlled substances (Schedule II medication, e.g., Ritalin, through Schedule V, e.g., cough syrup with codeine) should be counted weekly and recorded. (See Attachment J.) We recommend no more than a 20-day (one month) supply of Schedules II-V medication be brought to school by the parents. Contact the pharmacy if you are unsure as to whether a drug is a controlled substance or check the Physician s Desk Reference. It may be cost effective for the district to purchase pill-counting trays. Prior to the end of the school year, parents of students with leftover medication should be notified in writing and provided the opportunity to pick up the medication. If they do not pick up the medication in time, the medication should be counted by two school district staff, disposed of, and a statement verifying the counting and disposal should be dated and signed by the staff members. A good opportunity to send the parents a copy of the district's authorization to administer medications in the next school year is when the written notification of leftover medication is sent home at the end of the school year. This will give the parents all summer to get LHP authorization. (See Renton School District form /96 in Attachment K.) In addition to the requirements of the statute addressed in Section II, we also recommend that students be given the primary responsibility to go to the office for their medications. As a minimum, 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. For students receiving lunch time medications, parents can be instructed to

10 BULLETIN NO LATS Page 10 June 8, 2001 put a reminder in the student's lunch or the student could be reminded by school staff when the student picks up the lunch ticket. Procedures should be in place for addressing early school dismissal before a regularly administered medication is to be given. (See Attachment L.) 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 a tablet cutter. Tablet cutters can be purchased at a drug store. Also, ask the parents to have the pharmacist dispense two labeled containers, one for use at home and the other for use at school. This will obviate the need for medications to be transported between home and school or the medication at home to be in an improperly labeled bottle. If 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 the 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, but the school nurse must be confident that they came from the ordering LHP. The prescription bottle 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 and directs the nonnurse school staff person to use the available bottle. All new LHP requests or orders for medication should be approved by the school nurse prior to school staff administering the first dose. Health Care Providers Who May Prescribe The nurse practice act requires nurses to execute the medical regimen as prescribed by health professionals, including the LHPs identified in the oral medication statute. The law relating to nursing care including RCW (1) which lists the following health professionals as those that an RN may provide care at or under the general direction of: 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 (ARNP) acting within the scope of his or her license. (See Attachment M.) Licensed practical nurses (LPN) are required by RCW to carry out selected aspects of the designated nursing regimen under the direction and supervision of a registered nurse in addition to the above-listed health professionals. Currently, ARNPs with prescriptive authority may prescribe treatments and medications except for controlled substances in Schedules II-IV. They may prescribe Schedule V medications such as cough medications with codeine if registered with the Drug Enforcement Administration. With the passage of SSB 5805 by the 2000 Legislature, ARNPs will be permitted to prescribe Schedule II IV.

11 BULLETIN NO LATS Page 11 June 8, 2001 SSB 5805 provides that the Medical Quality Assurance Commission, the Board of Osteopathic Medicine and Surgery, and the State Nursing Care Quality Assurance Commission are directed to jointly adopt by consensus by rule a process and criteria that implements the joint practice arrangements authorized under this act and required for ARNPs to prescribe controlled substances. ARNPs will not be able to prescribe controlled substances Schedule II IV until the rules regarding the joint practice arrangements are adopted. The implementing regulations should be adopted by the end of calendar year In summary, nurses (RN, LPN) may accept and carry out orders for oral medications from licensed health professionals with prescriptive authority operating within their scope of practice, but only RNs and MDs can train and supervise non-nurse school staff in the administration of oral medications on requests from licensed health professionals. Security of Controlled Medications Medications should be stored in locked cabinets or locked drawers with access limited to those who need access to receive medications for use at school and/or to administer medications. Controlled substances stored in prescribers offices, hospitals, and nursing homes are required by law or rule to be stored in a securely locked, substantially constructed cabinet. It is reasonable that drugs and controlled substances used in schools should also be stored in a securely locked, substantially constructed cabinet or locked drawer. Because of reports of robberies of school buildings for drugs and reports of possible pilfering of controlled substances from school storage areas, OSPI recommends storing medications in a substantially constructed cabinet or locked drawer. Following are examples of what is considered by the Board of Pharmacy to be a substantially constructed cabinet: 1. Commercially manufactured safes. 2. Commercially manufactured drug security units made of heavy gage metal that are attachable to a wall or floor with single- or double-locking mechanism. 3. Noncommercially made cabinets made of metal, solid wood 0.5 thick, or plywood 0.75 thick with nonexposed hinges or nonremovable hinge pins if hinges are exposed. 4. A metal filing cabinet with a metal bar capable of being locked into position, blocking the opening of the drawers. This cabinet should be secured to the floor/wall or weighted sufficiently to prevent theft of the entire cabinet.

12 BULLETIN NO LATS Page 12 June 8, 2001 Cabinets constructed of particle board are not deemed to be substantially constructed. The integrity of this material is not suitable for attaching hinges or locking mechanisms. We would further recommend that in addition to the counting of medications as previously described in this section, keys to the cabinet be distributed only to those who need access to the medication cabinet and that not more than two keys be made to the cabinet. The keys should be assigned to and kept in the possession of those assigned staff. The key to the cabinet or desk should be different than the key to the office or room where the drugs are stored. We also recommend that Schedule II-V controlled substances be placed in an office safe over school holidays and weekends. Theft of any drugs should be reported to the supervising nurse, the building principal, the parent, and the district superintendent s office in order to monitor districtwide theft. Unless a large number of drugs are missing or the drugs were stolen in a burglary, a report to police may not be required, depending on the circumstances. We recommend that you check with local law enforcement and determine if or when they want to be notified of loss of controlled substances, at what level of loss, and establish procedures for compliance. Oral Medication Error Reporting in Schools The Nursing Care Quality Assurance Commission, with advice from the School Nurse Organization of Washington (SNOW) and the Superintendent of Public Instruction (OSPI), developed guidelines for identification and reporting of medication errors. The recommended procedures include analysis of medication error reports (Attachment H #1) to identify the need for changes in procedures, additional resources, and training necessary to reduce medication errors. The Oral Medication Error Reporting in Schools, Public and Private K-12, Guidance from the Washington State Nursing Care Quality Assurance Commission has been revised with the approval of the Nursing Commission. The original document is in Attachment H #2. The revised version follows: Policy Statement: The purpose of this policy is to ensure safe oral medication administration in the school systems. The correct oral medications must be administered to the correct student at the correct time, in the dosage prescribed, by the correct route. Deviation from this standard may constitute a medication error. A dose that is missed (omitted) may also be considered a medication error based on district policy. All medication errors must be documented and reported to the nurse who provides supervision for school staff giving the oral medications for the school under RCW 28A and 270. Analysis of the reports will be completed at least annually to determine any systems modifications that are necessary. This analysis will be reported to the school building administrator and forwarded to the district administration with recommendations.

13 BULLETIN NO LATS Page 13 June 8, 2001 Recommended Procedures: 1. All errors must be documented and reported to the supervising nurse for the school within 24 hours. 2. The supervising nurse, using clinical judgment, will determine the level of severity of the medication error. Serious errors must be reported immediately to the supervising nurse. 3. Counting of controlled substances at least weekly is highly recommended by the Board of Pharmacy. On weekly medication counts, the nurse needs to have assistance and a witness to the actual count of the medications. 4. If the error is committed by a credentialed 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 Mailing address: PO Box 47864, Olympia, WA Telephone number (360) The school administrator. Parents and/or guardians. The prescriber. 5. 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 and/or guardian by the supervising nurse. The incident may be reportable to the Department of Health, Unlicensed Practice Unit (360) This may be subject to administrative actions or fines. 6. All actions taken as a result of the medication error are to be documented on the written report. See Attachment H #1, Medication Error Report Form. 7. Theft or suspected theft is to be documented and reported to the supervising nurse. Theft or suspected theft may also be reportable to local law enforcement. 8. Medication error reports will be maintained for eight years after the incident (RCW ). The reports will be used by the supervising nurse to: Determine trends and patterns in medications errors, Assist in identification of educational and resource needs of licensed and unlicensed staff, and

14 BULLETIN NO LATS Page 14 June 8, 2001 Record circumstances contributing to the error and actions taken as a result of the error. 9. The supervising nurse may assess the results of actions taken in response to medication errors. VII. Field Trips and Medication Administration There are many issues to address before district staff should assume the responsibility for administering oral medications on field trips. Section 504 may apply to the participation of a student with a disability on a field trip and to the administration of oral medications to such a student during the field trip. If the student has an existing 504 accommodation plan requiring districts to administer oral medications at school, this plan would apply to field trips as well unless there were medical reasons not to take the student with a disability on the field trip. The district must investigate whether or not staff can safely accept responsibility for the student who has the right to the field trip and who may require medication on the field trip. There may be instances when the student should not go on the field trip because of the unstable/fragile nature of his/her condition and/or the nature of and/or the distance from the emergency care that might be required. There may be other solutions to permit the student to attend, such as: 1. Request the parent accompany the student and attend to the student s medical needs. 2. Assign an appropriately trained and licensed school staff person to care for the child on the trip. 3. The student carries his/her medication and self-administers with parent, LHP, and school nurse permission unless the student s Section 504 plan specifically states the district staff will administer the medication. Please note that if the student does not self-administer medication at school, the student will require training and support by parents and district staff before assuming this responsibility on a field trip. The parent, LHP, and school nurse must believe the student can safely take the medication and sign the permission form to do so. If none of these are possible, the school provides a comparable learning experience at school or in a safe location. All of the requirements of the oral medication statute must be met on the field trip, e.g., staff must be trained and supervised by an RN as is required when giving medication at school. (See Attachment N.) Students normally taking medication at home may need to take

15 BULLETIN NO LATS Page 15 June 8, 2001 medication while on a field trip extending beyond normal schools hours. Parents must be notified well in advance of the field trip. If parents indicate that medication not routinely given at school will need to be given on the field trip, then the authorization to administer medication must be completed and signed by parent and LHP prior to the field trip. (See Attachment O.) The medication will have to be supplied by the parent in the original pharmacy bottle. The medication will be carried on the field trip by the designated staff person(s) in a fanny pack or locked box with access limited to those giving the medication. The medication should be in the original pharmacy-labeled container. Prior to the field trip, the school nurse and the designated staff person record and sign a Field Trip Medication Log (See Attachment P) form with the name of the medication, the strength per dosage unit, the quantity, and the date. The form should have the following information: (1) name of student; (2) teacher and grade; (3) medication name; (4) dosage of medication to be given and dose per unit of medication; (5) time medication is to be given; and (6) a space for the designated and trained staff person to sign his/her name, date, and time the medication was given to the student. Upon returning to school from the field trip, the signed log sheet and any leftover medication is returned to the school nurse, who will transfer the information to the regular school medication log for the student. The school nurse and staff person should sign and date a log sheet that documents the return of the medication and any problems that might have occurred with the medication on the field trip. VIII. Disaster Planning/Medications When districts are planning for disaster situations, student medication issues must be addressed. There are two elements to consider: (1) The school should have at least a three-day supply of medications on hand for students who take medications during the school day, (2) the school nurse should question parents to identify medications that students normally take only at home and to whom the missing of three days of medications would pose a serious health risk for the student or others. The parent must then provide a three-day supply of these medications and the necessary parent and LHP requests and instructions for these medications. In some instances, by working with the student s LHP and parents, the need for the medication can be attenuated or delayed. For instance, insulin dosage may be altered based on food intake and activity level to require less insulin. Some medications may have a longer half-life permitting students to miss a number of doses without serious consequences. These situations will have to be identified and dealt with on an individual basis to ensure that those students needing medication receive the amount they need in situations where medications cannot be readily obtained without prior planning. All medications must be securely and properly stored according to prescription container directions, e.g., refrigerated and monitored for expiration dates. It may be necessary to rotate the school s stock of medications given only at home to ensure a fresh supply at school.

16 BULLETIN NO LATS Page 16 June 8, 2001 IX. Record Retention Requirements In April 1999, the Office of the Secretary of State and the Washington Association of School Business Officials issued the revised Records Management Manual and General Records Retention Schedule for School District. The health services records retention schedules lists program-specific records and the required retention period. (See Attachment Q.) The health room registry log and the medication administration daily log can be disposed of eight years after the last entry for the student. The medication administration case files can be disposed of eight years after the last dose. Conclusion The information in this Bulletin has been reviewed for accuracy by the Washington State Nursing Care Quality Assurance Commission, the Board of Pharmacy, and the Office of the Attorney General. If you have any question, please contact Judith A. Maire, Program Supervisor, Health Services, at (360) or TTY (360) This bulletin is available on the agency Web site at the following URL: Some bulletin attachments are available in hard copy only. To receive electronic copies of attachments, please contact the Health Services office at (360) OPERATIONS AND SUPPORT Marcia L. Riggers Assistant Superintendent Judith A. Maire, RN, MN Program Supervisor Health Services TB:JAM:dh Attachments

17 ATTACHMENTS

18 REVISED CODE OF WASHINGTON Page 1 of 2 RCW 28A Public and private schools -- Administration of oral medication by -- Conditions. Public school districts and private schools which conduct any of grades kindergarten through the twelfth grade may provide for the administration of oral medication of any nature to students who are in the custody of the school district or school at the time of administration, but are not required to do so by this section, subject to the following conditions: (1) The board of directors of the public school district or the governing board of the private school or, if none, the chief administrator of the private school shall adopt policies which address the designation of employees who may administer oral medications to students, the acquisition of parent requests and instructions, and the acquisition of requests from licensed health professionals prescribing within the scope of their prescriptive authority and instructions regarding students who require medication for more than fifteen consecutive school days, the identification of the medication to be administered, the means of safekeeping medications with special attention given to the safeguarding of legend drugs as defined in chapter RCW, and the means of maintaining a record of the administration of such medication; (2) The board of directors shall seek advice from one or more licensed physicians or nurses in the course of developing the foregoing policies; (3) The public school district or private school is in receipt of a written, current and unexpired request from a parent, or a legal guardian, or other person having legal control over the student to administer the medication to the student; (4) The public school district or the private school is in receipt of (a) a written, current and unexpired request from a licensed health professional prescribing within the scope of his or her prescriptive authority for administration of the medication, as there exists a valid health reason which makes administration of such medication advisable during the hours when school is in session or the hours in which the student is under the supervision of school officials, and (b) written, current and unexpired instructions from such licensed health professional prescribing within the scope of his or her prescriptive authority regarding the administration of prescribed medication to students who require medication for more than fifteen consecutive work days; (5) The medication is administered by an employee designated by or pursuant to the policies adopted pursuant to subsection (1) of this section and in substantial compliance with the prescription of a licensed health professional prescribing within the scope of his or her prescriptive authority or the written instructions provided pursuant to subsection (4) of this section; (6) The medication is first examined by the employee administering the same to determine in his or her judgment that it appears to be in the original container and to be properly labeled; and (7) The board of directors shall designate a professional person licensed pursuant to chapter RCW or chapter RCW as it applies to registered nurses and advanced registered nurse practitioners, to train and supervise the designated school district personnel in proper medication procedures. 9/17/2001

19 REVISED CODE OF WASHINGTON RCW 28A Public and private schools -- Administration of oral medication by -- Immunity from liability -- Discontinuance, procedure. (1) In the event a school employee administers oral medication to a student pursuant to RCW 28A in substantial compliance with the prescription of the student's licensed health professional prescribing within the scope of the professional's prescriptive authority or the written instructions provided pursuant to RCW 28A (4), and the other conditions set forth in RCW 28A have been substantially complied with, then the employee, the employee's school district or school of employment, and the members of the governing board and chief administrator thereof shall not be liable in any criminal action or for civil damages in their individual or marital or governmental or corporate or other capacities as a result of the administration of the medication. (2) The administration of oral medication to any student pursuant to RCW 28A may be discontinued by a public school district or private school and the school district or school, its employees, its chief administrator, and members of its governing board shall not be liable in any criminal action or for civil damages in their governmental or corporate or individual or marital or other capacities as a result of the discontinuance of such administration: PROVIDED, That the chief administrator of the public school district or private school, or his or her designee, has first provided actual notice orally or in writing in advance of the date of discontinuance to a parent or legal guardian of the student or other person having legal control over the student. [2000 c 63 2; 1990 c ; 1982 c Formerly RCW 28A ] NOTES: Severability c 195: See note following RCW 28A Page 1 of 1 9/17/2001

20 Policy No Students MEDICATION AT SCHOOL Under normal circumstances prescribed oral medication and oral over the counter medication should be dispensed before and/or after school hours under supervision of the parent or guardian. Oral medications are administered by mouth either by swallowing or inhaling including through a mask that covers the mouth or mouth and nose. If a student must receive prescribed or non-prescribed oral medication from an authorized staff member, the parent must submit a written authorization accompanied by a written request from a licensed health professional prescribing within the scope of his or her prescriptive authority. If the medication will be administered for more than fifteen consecutive days, the health professional must also provide written, current and unexpired instructions for the administration of the medication. The superintendent shall establish procedures for: A. Training and supervision of staff members in the administration of prescribed or nonprescribed oral medication to students by a physician or registered nurse; B. Designating staff members who may administer prescribed or non-prescribed oral medication to students; C. Obtaining signed and dated parental and health professional request for the dispensing of prescribed or D. Non-prescribed oral medications, including instructions from health professional if the medication is to be given for more than fifteen days; E. Storing prescribed or non-prescribed medication in a locked or limited access facility; and F. Maintaining records pertaining to the administration of prescribed or non-prescribed oral medication. G. Permitting, under limited circumstances, students to carry and self-administer medications necessary to their attendance at school. No medication shall be administered by injection except when a student is susceptible to a predetermined, life-endangering situation. In such an instance, the parent shall submit a written and signed permission statement. Such an authorization shall be supported by signed and dated written orders accompanied by supporting directions from the licensed health professional. A staff member shall be trained prior to injecting a medication. Medications administered by routes other than oral (ointments, drops, nasal inhalers, suppositories or non-emergency injections may not be administered by school staff other than registered nurses or licensed practical nurses. If the district decides to discontinue administering a student s medication, the superintendent or designee must provide notice to the student s parent or guardian orally and in writing prior to the discontinuance. There shall be a valid reason for the discontinuance that does not compromise the health of the student or violate legal protections for the disabled. Page 1 of 2

21 Policy No Students Legal References: RCW 28A Administration of Oral Medication by Conditions RCW 28A Administration of Oral Medication by Immunity from Liability Attorney General Memorandum (2/9/89) Administration of Medication Management Resources: Policy News, February 2001 Oral Medication Definition Expanded Adoption Date: School District Name: Revsied: Page 2 of 2

22 Procedure 3416P Medication At School Each school principal shall authorize two staff members to administer prescribed or nonprescribed oral medication. Oral medications are administered by mouth either by swallowing or inhaling and may include administration by mask if the mask covers the mouth or mouth and nose. These designated staff members will participate in an in-service training session conducted by a physician or registered nurse prior to the opening of school each year. Prescribed or over-the-counter oral medication may be dispensed to students on a scheduled basis upon written authorization from a parent with a written request by a licensed health professional prescribing within the scope of their prescriptive authority. If the medication is to be administered more than fifteen consecutive days the written request must be accompanied by written instructions from a licensed health professional. Requests shall be valid for not more than the current school year. The prescribed or non-prescribed medication must be properly labeled and be contained in the original container. The dispenser of prescribed or non-prescribed oral medication shall: A. Collect the medication directly from the parent, students should not transport medication to school, collect an authorization form properly signed by the parent and by the prescribing health professional and collect instructions from the prescribing health professional if the oral medication is to be administered for more than fifteen consecutive days; B. Store the prescription or non-prescribed oral medication (not more than a twenty (20) day supply) in a locked, substantially constructed cabinet; C. Maintain a daily record which indicates that the prescribed or nonprescribed oral medication was dispensed. D. Provide for supervision by a physician or registered nurse. A copy of this policy shall be provided to the parent upon request for administration of medication in the schools. Medications administered, other than orally, may only be administered by a registered nurse or licensed practical nurse. No prescribed medication shall be administered by injection by staff except when a student is susceptible to a predetermined, life-endangering situation. The parent shall submit a written statement which grants a staff member the authority to act according to the specific written orders and supporting directions provided by licensed health professional prescribing within his or her prescriptive authority (e.g., medication administered to counteract a reaction to a bee sting). Such medication shall be administered by staff trained by the supervising registered nurse to administer such an injection. Written orders for emergency medication, signed and dated, from the licensed health professional prescribing within his or her prescriptive authority shall: A. State that the student suffers from an allergy which may result in an anaphylactic reaction; B. Identify the drug, the mode of administration, the dose. Epinephrine administered by inhalation, rather than injection, may be a treatment option. This decision must be made by the licensed health professional prescribing within his or her prescriptive authority; C. Indicate when the injection shall be administered based on anticipated symptoms or time lapse from exposure to the allergen; Page 1 of 2