An Audit of Medication Administration: A Glimpse Into School Health Offices

INTRODUCTION

The climate of our schools has been affected by the large number of students with acute and chronic illnesses who require advanced medical technologies and medication administration during the school day. Federal legislation requiring inclusion for students with special needs in the least restrictive environment possible places greater responsibility on school districts to make the appropriate accommodations. Often these accommodations include the supervision and administration of medications during the school day to allow students with special health care needs to effectively participate in school programs.

School nurses are in a position of influence with regards to school medication policies, but frequently lack the time to administer medications directly to students. As a result, the task of medication administration is commonly assigned to school office staff. Office managers and secretaries often carry the responsibility for daily medication administration to students in addition to a myriad of other clerical duties. Competing demands in the school office are a constant reality. On any given day, the school secretary may be administering student medications, attending to a parent, and answering questions from a teacher, all at the same time. These factors, in addition to office staff’s lack of medical training, increase the likelihood of medication error.

Despite changes in the nature and complexity of the school nurses’ role, responsibility for oversight of medication administration is a vitally important duty. School nurses are well aware of the potential risks of delegating to unlicensed assistive personnel (UAP), but are left with few options given the number of students and schools they serve. The training and supervision of UAP becomes even more critical in light of these challenging circumstances. In response to this ongoing concern, the authors collaborated on a project, as part of the requirements for a School Nurse Credential Clinical Nurse Specialist class, focusing on the medication administration practices in their school districts. Using a representative sample of two school sites from each district, the authors performed a “medication audit” to review specific elements of medication administration practices and to identify areas that needed improvement.

LITERATURE REVIEW

Section 504 of the Rehabilitation Act (Public Law 93–112) requires schools to make reasonable accommodations for students with disabilities (US Department of Education, 1973). Many children with special needs and chronic diseases, such as diabetes, asthma, and attention-deficit hyperactivity disorder (ADHD), require medications that must be taken during school hours. While there are no national laws or standards that regulate the administration of medication in schools, many states have adopted specific policies for administration that apply to all of their schools. In 1991, the School Health Unit of the Massachusetts Department of Public Health recognized medication administration in schools as a priority for policy development (Sheetz & Blum, 1998). Recognizing the lack of national standards, the American Academy of Pediatrics’ Committee on School Health recently published recommended guidelines for administration of medication in schools (Taras, Frankowski, McGrath, Mears, Murray, & Young, 2003).

A literature review of medication management in schools covering research published in the past 10 years identified 10 studies primarily using surveys to school administrators, school nurses, and school secretaries (Table 1). Five studies were national in scope, and five were limited to specific states and geographical areas. A common theme in all 10 studies was that medication administration in schools was often problematic. Although the majority of school nurses delegated medication administration responsibilities to others, neither school nurses nor school secretaries felt comfortable with existing procedures. Additionally, medication errors were commonly found.

One study surveyed 649 school nurses and found an average of 5.6% of children receive medication at school during a typical day (McCarthy, Kelly, & Reed, 2000). The most common medications given were for ADHD, with an average of 3.3% students receiving these medications. Other common medications included nonprescription preparations (1.5%), asthma medications (1.1%), and analgesics (0.9%). Almost all nurses reported they had written school or district guidelines and state guidelines. In addition, a written physician’s order was required to administer prescription medications. The most common problems reported were documenting side effects of medications and storage of medications. Medication delegation to UAP was found to be a common practice (75.6%), with school secretaries being the most common UAP (66.2%). Nearly half (48.5%) of school nurses reported errors in administering medications in the previous year, with missed doses (79.7%) being the most common error.

Two qualitative national studies examined school nurses’ experiences with medication administration. School nurses in both studies reported multiple areas of concern: delegation of medication administration, comfort with delegation, student self-administration of medications, medication administration errors, storage of medications, and administration policies (Kelly, McCarthy, & Mordhorst, 2003; Reutzel & Rinku, 2001). A study of school secretaries’ experiences and perceptions regarding administering medications revealed that only one in four had received any training on medication administration, and half received a training of two hours duration or less. Secretaries typically disliked dispensing medications to students, even while reporting that most (64%) administered medication 5 days per week (Price, Dake, Murnan, & Telljohann, 2003).

Five studies limited to specific geographical regions revealed similar trends in medication administration and concerns about safety and liability. A study of schools in Iowa found that while policies regarding medication administration in schools were common, policies were lacking for field trips. Major factors contributing to medication errors included poor communication and confusion over medication responsibility (Farris, McCarthy, Kelly, Clay, & Gross, 2003). A Florida study revealed that nonhealth professionals assigned by the school principal dispensed the majority of medications (Francis & Hemmat, 1996). Massachusetts developed and implemented statewide medication administration regulations partly due to more than 50 weekly telephone calls from school health personnel regarding the subject (Sheetz et al., 1998). Ficca and Welk (2006) examined medication administration policies and practices in Pennsylvania schools. They found that only 67% of the guidelines for medication administration incorporated documentation criteria, and 56% of the schools did not have policies regarding medication administration for field trips. Seventy percent of the nurses responded that they did not administer all the medications in their schools. Errors increased if the nurse was responsible for more than three buildings and if there were more than three different UAP administering medications. In addition, nurses were concerned that conflicting medication administration guidelines and laws created difficulty in adhering to the Nurse Practice Act.

Several studies suggest recent changes in the type and number of medications administered in school, specifically as a result of the introduction of long-acting stimulants that no longer need be taken at school. A recent study of Kansas schools showed lower rates (1.91%) of medication administration for attention-deficit/hyperactivity disorder than reported in earlier publications (Weller, Fredrickson, Burbach, Molgaard, & Ngong, 2004). Another recent study suggests that the use of long-acting stimulants has significantly reduced the number of prescription medications administered in schools (McCarthy, Kelly, Johnson, Roman, & Zimmerman, 2006).

In summary, administration of medications in schools continues to present challenges due to the structure of the school environment, lack of school nurses, delegation of medication administration, and lack of understanding about state and district policies. School nurses are the only school personnel with health care knowledge, and they often are left to interpret and implement medication administration policies.

SETTING

Five school nurses planned and participated in a medication administration audit that included eight public schools, representing four school districts in three counties in Northern California. Additionally, two county school centers serving children who are medically fragile or have severe learning disabilities in one of the three counties in this area participated in the audit. Geographically, the area is suburban and includes some extremely impoverished neighborhoods as well as some that are very wealthy. The student population at the schools audited reflected this socioeconomic diversity. The percentage of students qualifying for the free and reduced meal program at these schools varied from 25% to 85% of the student population. Students from these schools mirrored the ethnic diversity of the area, which included Latino/Hispanic, African-American, Asian, and Pacific Islander communities.

The four school districts ranged in enrollment from approximately 4,200 to 7,400 students. The school nurse to student ratio of four districts and two school centers ranged from 1:210 to 1:7,400. However, the school nurse with the smallest assignment was meeting the health needs of all special education students at the county school centers. The 10 schools audited were all elementary schools, Kindergarten through 8th grade, and included both regular and special education classes.

Medication administration at these school sites was carried out by school office staff, which may be a health clerk and/or an office secretary or office manager, and supervised by the school nurse. In two school centers, staff designated to give medication also included classroom teachers and aides. All health clerks, office, and classroom staff were unlicensed assistive personnel (UAP) with no nursing or medical background, however all were required to be trained and certified in CPR and First Aid. Training in medication administration and management was conducted by school nurses annually at the beginning of each school year at all school sites. School nurses provided this training to ensure that medication administration followed district protocols and guidelines to ensure the health and safety of children. Training emphasized the five rights of safe medication administration: right student, right drug, right dose, right time, and right route, as well as discussion of medication side effects, appropriate documentation, and storage of medications.

DATA COLLECTION PROCEDURE

School nurses conducted the medication audit using a Medication Audit Form (Figure 1). This form guided the collection of data and was used to record information on every medication administered at all 10 school sites. This information was obtained from school medication logs and records, physician authorization forms, and medication prescription labels. The name of the medication ordered, dose, and time the medication was scheduled to be administered were recorded for each prescription and over-the-counter medication from the physician authorization forms. This information was then compared to the prescription labels on the medication to verify transcription accuracy. Medication expiration dates from the prescription labels were recorded. School logs and records for every medication administered were checked to determine if the medication was given the number of times it was scheduled to be given and if it was given at the correct time. An Excel© spreadsheet was used to group these categories and calculate percent of error. Explanation of errors, additional problems discovered during the audit, and anecdotal statements from office personnel responsible for administering medication were also recorded.

RESULTS

Medication errors were identified in all categories audited, and discrepancies varied by school. Table 2 shows the analysis of the data collected from the 10 schools on the 154 medications prescribed for students to be given at school. In the category citing the number of times medications were not given on time, the window of time included one half hour before and one half hour after the prescribed time as written on the physician’s authorization form. Of the 154 medications prescribed, 22 were not transcribed accurately. Some of these errors involved the dose to be given; for example, the order stated “1 tablet,” but did not state the number of milligrams per tablet. Five prescribed medications did not match the physician’s order; for example, the prescription label stated “Metadate,” but the order stated “Methylin ER.”

Of the 1,481 times medications should have been given, days in school minus days absent from school, medications were not given 44 times. Nothing was noted on school medication records as to why these medications were not given. Additionally, medications were not administered at the time prescribed in 186 cases, and the reasons why this occurred were not recorded. One school did not record time the entire school year; they changed the school medication log to a monthly calendar format and only placed staff initials in the space for each day that the medication was given. The medication training for this school took place a week prior to school starting and included discussion of the five rights, including right time and documentation of same. The staff stated that this was an “easier and faster” method to record administering the medication; they did not realize they were neglecting to record the time they gave the medication. At a different school, staff only initialed the medication log once a week at the end of each week, instead of daily each time medication was administered. Another school only recorded administering prescription medication, but not over-the-counter (OTC) medications.

Additional problems were discovered during the medication audit and were recorded in a comment section on the Medication Audit Form. Some problems were common among several school sites, and some were only a concern at one, but problems were revealed at all school sites in addition to the ones specifically noted on the audit form. Several issues with storage were found. One school did not store OTC medications in the locked cabinet with the prescription medications. Office staff at two schools did not always contact the school nurse, as per school district requirements, when parents sent in a different brand of OTC medication than that prescribed by the physician. Three OTC medications located in the medication cabinet did not have physician authorization forms. Several inhalers did not have spacers when spacers were part of the medication orders. Two liquid medications did not have a device to accurately measure the dosage. When asked how the medication would be administered, the office staff stated they would “get a spoon from the staff lounge.” At one school, six medications from the previous year, which had either expired or for which the school no longer had a current order, were stored in the same locked cabinet with the current year’s medications. Consequently, two expired inhalers and two nonexpired inhalers for the same two students were all placed in the cabinet together, increasing the chance that the expired medications could be given to the student inadvertently. Finally, several other medications, specifically four epinephrine auto-injector pens for allergic emergencies, had expired.

DISCUSSION

The purpose of this audit was to evaluate the medication administration process at multiple school sites, with a focus on safe and accurate medication administration, management, and documentation. The goal was to identify errors and discrepancies and to make recommendations for change as indicated.

UAP dispense medications administered at the schools that participated in the audit, including health clerks, school secretaries, and classroom teachers or aides. Previous studies supported this finding. McCarthy, Kelly, and Reed (2000) found that delegation of medication administration to UAP occurred in 75.6% of the respondents. Price and colleagues (2003) found that 64% of school secretaries administered medications at least 5 days per week. Delegating medication administration to UAP is a consistent practice throughout the United States. Supervision of UAP by credentialed/certified school nurses is critical to accuracy in medication administration.

Results of this study indicate many medication errors, including incorrect medication dosage, missed dosage, expired dates, inconsistent recording, inappropriate medication storage, missing or expired physician authorization forms, inaccurate transcription, and disorganized record keeping. Inaccurate time of administration occurred in 12.5% of the medications audited, and missed doses occurred in 29.7%. These findings are similar to the findings reported by McCarthy, Kelly, and Reed (2000), who identified that missed doses of medication (79.7%) was the most common error. Proper storage, accurate dosage measurement, expired medications, and documentation errors were also noted as frequently occurring problems. Kelly, McCarthy, and Mordhorst (2003); and Reutzel and Rinku (2001) reported similar findings. The consistency of findings in this and other previous studies supports the importance of identifying strategies to increase the accuracy of medication administration in school settings.

IMPLICATIONS FOR SCHOOL NURSE PRACTICE

The administration of medication in schools has changed in recent years. Even though there has been a reduction in the number of medications in recent years, the range and complexity prescribed has dramatically increased (McCarthy et al., 2006). The knowledge and expertise of school nurses is more vital than ever. It is the school nurses’ responsibility to ensure that UAP who have been delegated the task of medication administration are well trained and understand the importance of meticulous administration and documentation. School nurses can not rely on annual medication administration training for UAP. To ensure safe medication administration in schools, it is important to have an ongoing evaluation process throughout the school year and periodically review medication logs. The medication audit data collection form can be used in multiple school settings to collect information that will highlight possible medication administration problems. Data collected can point to deficiencies of training and/or lack of understanding of protocols and the steps associated with safe and accurate medication administration. Refresher instruction can be designed to meet the UAP’s identified needs either individually or as a group. Unlicensed assistive personnel do not have the medical background to make decisions regarding medication administration. School nurses need to be vigilant in the supervision of UAP to ensure safe medication administration and proper documentation in the school setting.

CONCLUSION

Many students come to school requiring medication for both chronic and episodic illnesses. Issues of concern include the level of responsibility schools have in providing medication administration services, the amount of nursing time involved, and the amount of staff training time needed to correctly manage medication administration in a school setting. This is a safety issue that can potentially lead to litigation. School districts need to review and renew medication administration policies and guidelines to clearly state who is responsible for medication administration, to whom this task can be delegated, how the medications should be stored, how the process should be documented, the amount of training UAP need, and how to recognize and handle medication errors. Written policies should also include a plan for medication administration during field trips and sports events, as well as policies for self-administration of medications, such as inhalers for children with asthma.

Regardless of who is legally responsible for medication administration, school nurses are expected to have the expertise and the resources to manage this process. The result of this audit has identified the need for additional nursing time to closely monitor the medication administration process and to make recommendations for change. Factors that contribute to errors include insufficient training time, high student-staff ratio, inadequate nurse-student ratio, and low priority for safe medication administration practices. The authors recommend medication audits, affording school nurses a glimpse into how medication is managed at their school sites. This information will identify the strengths and weaknesses of the process and encourage appropriate changes.