Many children who take medications require them during the school day. This policy statement is designed to guide prescribing health care professionals, school physicians, and school health councils on the administration of medications to children at school. All districts and schools need to have policies and plans in place for safe, effective, and efficient administration of medications at school. Having full-time licensed registered nurses administering all routine and emergency medications in schools is the best situation. When a licensed registered nurse is not available, a licensed practical nurse may administer medications. When a nurse cannot administer medication in school, the American Academy of Pediatrics supports appropriate delegation of nursing services in the school setting. Delegation is a tool that may be used by the licensed registered school nurse to allow unlicensed assistive personnel to provide standardized, routine health services under the supervision of the nurse and on the basis of physician guidance and school nursing assessment of the unique needs of the individual child and the suitability of delegation of specific nursing tasks. Any delegation of nursing duties must be consistent with the requirements of state nurse practice acts, state regulations, and guidelines provided by professional nursing organizations. Long-term, emergency, and short-term medications; over-the-counter medications; alternative medications; and experimental drugs that are administered as part of a clinical trial are discussed in this statement. This statement has been endorsed by the American School Health Association.
School boards and districts are responsible for policies and procedures for administration of medications to students who require them during the school day. The health circumstances that require medication are diverse. Medical advances have enabled many students with special health care needs or chronic health conditions to be included in classes with their peers.1 Some schools struggle to balance the need for health care services for increasing numbers of children with special health care needs with the current resources available to provide those services.2–12
The presence in schools of a full-time licensed registered school nurse is strongly endorsed.13 Registered nurses (RNs) have the knowledge and skills required for the delivery of medication, the clinical knowledge of the student's health, and the responsibility to protect the health and safety of all students. The use of untrained school staff to administer medications to children with special health care needs creates risks, not only of medical liability for the school and the licensed registered school nurse but also of medication error for the student.14–16 To ensure the health and safety of students, all schools should have a full-time licensed RN who has the knowledge and skills required for the delivery of medication and the assessment of student health.17,18
This policy statement has been endorsed by the American School Health Association.
TRAINED UNLICENSED ASSISTIVE PERSONNEL
When a school nurse is not available at all times, the American Academy of Pediatrics (AAP), the National Association of School Nurses, and the American Nurses Association recommend trained and supervised unlicensed assistive personnel (UAP) who have the required knowledge, skills, and composure to deliver specific school health services under the guidance of a licensed RN. UAP duties are delegated by a licensed RN.19,20 Training and supervision of UAP are necessary for providing safe, accurate, and timely administration of medication. Delegation is a tool that may be used by the licensed registered school nurse to allow UAP to provide standardized routine health services under the supervision of the nurse and on the basis of physician guidance and school nursing assessment of the unique needs of the individual child and the suitability of delegation of specific nursing tasks. Any delegation of nursing duties must be consistent with the requirements of state nurse practice acts, state regulations, and guidelines provided by professional nursing organizations. Delegation of nursing duties is the responsibility of the certified licensed school nurse or licensed RN. The nurse determines which nursing services can be delegated and then selects, trains, and evaluates the performance of UAP; audits school medication records and documents; and conducts refresher classes throughout the school year.21–23 The training, certification, and supervision of UAP should be determined by national and state nursing organizations and state nurse practice laws. Delegation is an ongoing process and a management tool, not a once-a-year event.
UAP training is typically limited and specific for medication-administration tasks and cannot replace a nursing assessment. In most circumstances, a medication UAP should be an ancillary health office staff member (health assistant/aide) who is also trained in basic first aid and district health office procedures. On rare occasions when a member of the health office staff (RN, licensed practice nurse, or UAP health assistant/aide) is not available, other willing volunteer school staff may be trained by the licensed RN to assume specific limited tasks such as single-dose medication delivery or life-saving emergency medication administration. In those instances, it is important for school districts to identify and satisfactorily address medical liability issues for the school district, the nurse, and the voluntary nonmedical staff member who is serving temporarily as UAP.
SCHOOL POLICY AND PROCEDURES
Section 504 of the Rehabilitation Act and the Individuals With Disabilities Education Act (IDEA) provide protection for students with disabilities by requiring schools to make reasonable accommodations and to allow for safe inclusion of these students in school programs.24–27 These federal laws apply only to schools that receive federal funds, do not cover all students who require medications during the school day (eg, short-term needs), and are not specific about how administration of medications should be conducted in school. The AAP supports state laws, regulations, or standards that establish more specific policies for administration of medications that apply to all of the state's school districts. State standards can limit discrepancies among school districts within the state and reduce confusion for parents and prescribing health care professionals. School boards and school superintendents are responsible for establishing policies and detailed procedures for the safe administration of medication in the school setting. When state standards are insufficient, school health professionals, consulting physicians, and school health councils can work with AAP chapters to promote improved state standards and assist with local policies and procedures. Individual school districts also might wish to seek legal advice as they assume the responsibility for giving medication during school hours and during activities at school before or after school hours. Liability coverage should be provided for the staff, including nurses, teachers, athletic staff, principals, superintendents, and members of the school board.15 Any student who must take medication during regular school hours should do so in compliance with all federal and state laws and school district policies.
Guidance for pediatricians, school physicians, and school health consultants is consistent with policy declarations of the National Association of School Nurses28 and the American Nurses Association.20 The following are recommendations for school districts in implementing medication-administration policies and procedures.29
Protect student safety and prevent medication errors. Nursing services at school, whether emergent, urgent, or routine, require the creation of a confidential, timely, and accurate record of the service provided.
Identify the licensed health professional (certified or registered school nurse or school physician) on the school staff who supervises and is responsible for the safe keeping and accessibility and administration of medications, including documentation and a system of accountability for students who carry and self-administer their medications.
Use a systematic review of documentation of medication-administration records for quality improvement, especially to reduce medication errors and to verify controlled substance counts.
Create an ongoing training and certification program for UAP who perform specific nursing services when delegated and supervised by the licensed school RN or school physician.
Establish and follow effective communication systems that support the school's nursing plan (individualized health plans, etc) and promote accurate implementation of the prescriber's instructions for the medical management of a designated student's health needs.
Require a written medication form, signed by the authorized prescriber and parent, with the name of the student, the drug, the dose, approximate time it is to be taken, and the diagnosis or reason the medication is needed. This requirement applies for all prescription medications.
Require written parental approval if over-the-counter (OTC) medications are permitted. Limit the duration that an OTC medication is administered at school.30 Use of OTC medications over an extended time period warrants an authorized prescriber's oversight and authorization.
Train, delegate, and supervise appropriate UAP who have the knowledge and skills to administer or assist in the administration of medication to students when assessed to be appropriate by the supervising and delegating licensed registered school nurse or school physician in compliance with applicable state laws and regulations.
Permit responsible students to carry and self-administer emergency medications for those conditions authorized by school policies and regulations, which also describe students’/parents’ rights and responsibilities.34,35
Provide and encourage parents to provide spare life-saving medications in the health office for students who carry and self-administer emergency medications in the event that the life-saving medication cannot be located when a student is in need of the medicine.
Make provisions for secured and immediate access to emergency medications at school at all times, including before and after school hours and during students’ off-campus school-sponsored activities.35–39
ADMINISTRATION OF LONG-TERM MEDICATIONS
Long-term medications are those needed to manage a student's symptoms or promote health over an extended period of time. Many students who require long-term medications are children with special health care needs whose school attendance and participation in school activities depend on the administration of the prescribed treatment. Asthma, attention-deficit/hyperactivity disorder, seizures, heart conditions, cerebral palsy, and diabetes mellitus are among the common conditions that require medication at school.40–42 Although not common, students infected with HIV may require multiple medications during the school day. In most cases, school nurses will develop individualized health plans for children with special health care needs.43
School nurses should review all school medication orders, establish liaisons with the student's health care professionals, administer medication, and/or provide effective training and supervision of UAP who are delegated to administer medication.13,44 Requests to administer nonstandard medications (eg, doses in excess of manufacturer guidelines; alternative, homeopathic, or experimental medications; nutritional supplements) do not have to be honored by a school nurse. However, a school nurse has a professional obligation to promptly record the request and resolve the conflict with the parent, the prescriber, and/or, when needed, the school physician.45
EMERGENCY AND URGENT MEDICATIONS
Emergency and urgent medications are often given by nonoral routes and are administered to initiate treatment or amelioration of a disease or condition that may be life-threatening or cause grave morbidity. The complexity and urgency of this intervention is the focus of the AAP policy statement “Medical Emergencies Occurring at School,”36 which describes prevention and mitigation of emergent events and stresses the role of the school nurse in providing this nursing service at school. The school nurse is the professional most likely to train school staff, to create a liaison with community emergency response teams and other health care professionals, and to assist, in coordination with the school physician, the school administration in development of policies and administrative regulations concerning medical emergencies.17,34,36,37,46–48 State laws or regulations designate the roles and responsibilities of school staff in this situation. They may specifically limit or expand the role of UAP in emergency care settings. Some states have legislated authority to create protocols and procedures through which school staff are identified, trained, and certified to initiate medical care in a medically urgent or emergent situation and to address concerns of liability for nursing services provided under such conditions.49–51
Immediate access to emergency medications (eg, autoinjectable epinephrine, albuterol, rectal diazepam, and glucagon) is a high priority and is crucial to the effectiveness of these life-saving interventions. To maintain medication security and safety and provide for timely treatment, local procedures must specify where medications will be stored, who is responsible for the medication, who will regularly review and replace outdated medication, and who will carry the medication for field trips. In addition to unlicensed health office staff, other school staff may be trained, designated, and supervised as emergency UAP to be “first responders” to a student who experiences a medical emergency.
Schools also need an adequate supply of emergency medications in the event of a school lock-down or evacuation. Parent-supplied extra medication and/or school-supplied stock medications (including but not limited to autoinjectable epinephrine and albuterol inhalers) are among the emergency or urgent care medications that need to be available in these circumstances.37,38,52
SECURITY AND STORAGE OF MEDICATIONS
All prescription medications brought to school should be in original containers appropriately labeled by the pharmacist or physician. Except for self-carry medications, they should be stored securely in accordance with manufacturer directions. Controlled substances must be double-locked.53 The school nurse, licensed practice nurse, or delegated, trained UAP must be available and have access to the medications at all times during the school day. All medications should be returned to the parents at the end of the school year or disposed of in accordance with existing laws, regulations, or standards. Care should be taken not to flush any drugs into the water system unnecessarily.
STUDENT SELF-CARRYING AND SELF-ADMINISTRATION OF PRESCRIBED MEDICATIONS
A responsible student should be permitted to carry medication for urgent or emergency need when it does not require refrigeration or security, according to policies determined by the school in accordance with laws, regulations, and standards.34,54 Controlled substances and those at risk of drug abuse or sale to others are not appropriate for self-carrying. The student's personal health care professional, the parents, and the school nurse and school physician should collaboratively determine the ability of a student to appropriately self-administer the prescribed medication in a responsible and secure manner. School personnel must also permit the student to possess and take the medication once a determination has been made that the student is mature enough to carry and self-administer the medication. Some schools use self-administration agreements or have given a “medication pass” to students, verifying school permission for the student to carry and take medication. The student's ability to appropriately self-administer the prescribed medication must be evaluated by the school nurse at regular intervals to ensure safety and correctness of administration. For elementary school–aged children, the self-administration of a dose of medication should be reported to school personnel as soon as the self-administered dose is given for documentation and assessment of need for additional assistance. Medications carried by students should be either on the person of the student, as in a dedicated “fanny pack,” or in possession of a supervising adult who will return the medication pack to the student as needed or when the student moves on to a new location. Medications should not be left unattended.
School administrators and health personnel should consider whether the benefits of administration of OTC medications outweigh the risks. Some states and school districts apply the same standards for OTC as for prescription medications. Others permit parent-recommended OTC medications or dietary supplements to be administered without a physician order. Either approach can be problematic. Providing parent-approved short-term medications, such as pain relievers, antiinflammatory medications, and antihistamines, for example, may provide symptomatic improvement for the student, which enables attendance for learning and causes less classroom disruption. However, this practice can result in liability for a school district, because nonprescribed medications have potential to cause harm or adverse effects that may impede learning. There are also issues of school safety and security of drug use (eg, sharing of medication between classmates when OTC medications are not stored in the school health office). On the other hand, 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. It can be difficult to obtain physician authorization for OTC medications. Because of these realities, it may be necessary to consider allowing the administration of nonprescribed, parent-recommended medications for students during the school day on a short-term basis. The relative value of OTC medications for the specific population should guide policies. Cold and cough OTC medicines have not been shown to be effective in children younger than 6 years and are not appropriate for use at school without a physician order.55 When OTC medications are permitted, school physicians and school nurses should develop standing protocols or standing orders that support 1-time verbal parental permission for specific OTC medications (eg, acetaminophen and ibuprofen).28,30,56
Alternative medications, such as herbal or homeopathic medications, are not tested by the US Food and Drug Administration for safety or effectiveness. Lack of safety information for these medications limits their appropriate use at school.57 State and district medication policies should be used for alternative medications. These medications should never be administered without a written physician order. State and district policies should also address experimental medications and medications administered at doses in excess of manufacturer guidelines.58
Recommendations for Pediatricians and Other Child Health Professionals
The AAP recommends that pediatricians and other prescribing pediatric health care professionals take the following actions when writing prescriptions for students:
Prescribe medications for administration at school only when necessary. Many short-term and long-term medications can be given before and after school.
Learn about local school nursing services, medication policies and forms, and self-administration procedures.
Write specific, clear, and detailed instructions on dated, standardized school medication forms. Consider that the “need to treat” may be delegated to UAP.
Carefully assess and declare in writing your recommendation concerning students’ self-carrying/self-administration on the basis of your patient demonstrating the appropriate developmental, physical, and intellectual capacity to self-carry and/or self-administer an emergency medication at school (see National Asthma Education and Prevention Program guidance34 ).
Collaborate with school physicians and school nurses and encourage parental collaboration.
Promote student health by advocating for coordinated school health programs.
Advocate for improved communication systems among schools, families, and pediatricians that support medication-administration services for students at school.
Advocate for improved school medication data collection and reporting by schools and school nurses.
Participate on your district's school health council. School health councils offer an opportunity for the development of collaborative liaisons among school administrators, licensed school health staff, and community health professionals.
Recommendations for Public Advocacy
The AAP recommends that pediatricians and other child health professionals and their state professional organizations take the following actions:
Participate on or support the creation of a district school health council to promote student health and improved communications in a coordinated school health program;
Work with state departments of health and/or education, state and local school boards, and school districts to ensure the development and funding of adequate school health program staffing and sound school medication policies and procedures as outlined in this statement; and
Support state laws, regulations, or standards that establish specific policies for the safe and effective administration of medications in schools that apply to all state school districts.
COUNCIL ON SCHOOL HEALTH EXECUTIVE COMMITTEE, 2008–2009
Robert D. Murray, MD, Chairperson
Rani S. Gereige, MD, MPH
Jeffrey H. Lamont, MD
*George J. Monteverdi, MD
Evan G. Pattishall, III, MD
Michele M. Roland, MD
*Lani S.M. Wheeler, MD
Cynthia DiLaura Devore, MD
Stephen E. Barnett, MD
Wendy Anderson, MD
Jeffrey Okamoto, MD
PAST COUNCIL EXECUTIVE COMMITTEE MEMBERS
Linda M. Grant, MD, MPH
Harold Magalnick, MD
Alex B. Blum, MD
Section on Residents
Sandi Delack, RN, MEd, NCSN
National Association of School Nurses
Mary Vernon-Smiley, MD
Centers for Disease Control and Prevention
Robert Wallace, MD
Independent School Health Association
Madra Guinn-Jones, MPH
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict-of-interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.