Medication Administration in Schools
It is the position of the National Association of School Nurses (NASN) that the registered professional school nurse (hereinafter referred to as school nurse) be responsible for medication administration in the school setting, leading the development of written medication administration policies and procedures that focus on safe and efficient medication administration at school. Well-written policies and procedures will enable schools to fulfill their obligations to provide health-related services to all children, including those with special healthcare needs under the Individuals with Disabilities Education Improvement Act (2004) and Section 504 of the Rehabilitation Act (1973) as amended through the Americans with Disabilities Amendment Act [ADAA] in 2008.
Policies and procedures should address (Ryan, Katsiyannis, Losinski, Reid, & Ellis, 2013; U.S. Food and Drug Administration [FDA], 2013):
delegation (when permissible by state law), training and supervision of unlicensed assistive personnel (UAP);
medication doses that exceed manufacturer's guidelines;
proper labeling, storage, disposal, and transportation of medication to and from school;
documentation of medication administration;
rescue and emergency medications;
off-label medications and investigational drugs;
prescription and over-the-counter (OTC) medications;
complementary and alternative medications; and
psychotropic medications and controlled substances.
The administration of medication by non-nursing school staff, when allowed, should be addressed (Ryan et al., 2013). These policies and procedures shall be consistent with federal and state laws including state nurse practice acts, rules, regulations, and any other laws that may apply, as well as standards and established safe, evidence-based information (Ryan et al., 2013; Bobo, 2014).
Medication administration to students is one of the most common health‐related activities performed in school. Historically, administering medication within the school setting has been a school nurse responsibility. However, as many districts and schools struggle financially, it is not uncommon for students to receive medication from non-nursing school employees who have had no medical training. This trend has caused an alarming increase in the number of medication errors made by UAP (Institute for Safe Medication Practices [ISMP], 2012). It is especially important that evidence-based medication policies and procedures be in place in those schools where a registered nurse is not present every day.
It is estimated that up to 27% of children have chronic health conditions (Van Cleave, Gortmaker, & Perrin, 2010). As more students with chronic conditions enter school systems each year, awareness of the factors which can promote and support their academic success increases. This includes the need for medications which enhance students’ overall health or stabilize their chronic health conditions.
Medications, when administered and used appropriately, can improve student health but may be harmful if administered incorrectly. Errors in medication administration are the most common medical errors (Cloete, 2015). Examples of medication errors include administering medication to the wrong person, giving the wrong dose, or not giving a dose as scheduled. For the safety of students, it is critical that evidence-based policies and procedures exist regarding medication administration. School nurses have the health expertise needed to develop, promote, and implement policies that are evidence-based; reduce errors; and increase the proper use and storage of medications in school settings (American Academy of Pediatrics [AAP], 2016; ISMP, 2012).
To reduce errors and increase safety, written policies and procedures for schools should include documentation from a licensed provider for the medication; proper labeling of medications brought to school; training of other staff involved in medication administration; storage of medication; process for administering medication (including proper identification of student and medication); documentation of medication administration, errors, reactions or side effects of medication; and proper disposal of medications (National Coordinating Council for Medication Error Reporting and Prevention [NCCMERP], 2007; 2015; FDA, 2013; Ryan et al., 2013). The principles of leadership, care coordination, quality improvement, public health/community, and standards of practice guide the practice of school nurses, including their role in medication administration (NASN, 2016).
As the expert healthcare provider in the educational setting, the school nurse is critical to the safe and effective administration of medication to students. The school nurse should lead in the development, implementation, and evaluation of medication administration policies and procedures at the school or district level. Training and supervision of UAPs who administer medications should be done by the school nurse, and consideration of safety and school nurse workload is essential. There is a decrease in errors when a culture of safety exists that includes proper oversight and written policies in place (U.S. Department of Health and Human Services [USDHHS], 2011).
School medication policies and procedures must be in accordance with all applicable laws, including nurse practice acts (NPA). For example, delegation and training are often specifically noted in states’ NPAs. Registered nurses possess the knowledge about how to comply with NPAs and issues such as over-the-counter medications, off-label usage, and alternative medications in a safe, evidence-based manner (American Nurses Association [ANA], 2012; AAP, 2016).
Medication administration is often part of a larger plan for the care and management of acute and chronic health conditions. There must be communication and collaboration between parents, providers, and schools regarding each student’s medication that describes what is to be given, the purpose, frequency, and side effects of the medication (NCCMERP, 2007; American Academy of Pediatrics, American Public Health Association, & National Resource Center for Health and Safety in Child Care and Early Education, 2011). School nurses are the health professionals in the school who coordinate care for the student, including medication administration.
The necessity for student use of medication at school has risen over the last two decades because many students who attend school have complex and chronic medical problems (ISMP, 2012). Research has shown that there are fewer medication errors in schools when medications are provided by a school nurse and when evidence-based policies are routinely followed (ISMP, 2012). Medication policies and procedures should include provisions for evaluation of medication practices and policies, including reviews of documentation and occasional audits, to identify possible concerns and adjust practice or policy as needed (USDHHS, 2011).
School nurses understand the unique needs and environments of their populations, which should be addressed in schools’ medication policies and guidelines (NCCMERP, 2015). School nurses can identify and address issues that may affect management of acute and chronic health conditions, such as environmental factors and socio-economic challenges, including obstacles to obtaining medications and delivery of medication to the school (Blaakman, Cohen, Fagnano, & Halterman, 2014). Evidence indicates that school nurses can provide culturally appropriate, sensitive information for students and families regarding management of health issues, including proper use of medications (McNaughton, Cowell & Fogg, 2014).
The school nurse should lead the development of school district policies and procedures relating to medication administration in the school setting and, where delegation of medication is permitted, the school nurse should be responsible for the delegation, training and supervision of UAP. The school nurse is the professional with the clinical knowledge and understanding of the complex issues surrounding the safe administration of medication and the responsibility to protect the health and safety of students (AAP, 2016; ANA, 2012). As the health leader in the school setting, the school nurse promotes current evidence-based practices so students requiring medication during the school day can safely have their needs met and remain in school ready to learn (Maughan, 2016).
American Academy of Pediatrics (AAP). (2016, June). Role of the school nurse in providing school health services (Policy Statement). Pediatrics, 137(6), 1-6. doi: 10.1542/peds.2016-0852
American Academy of Pediatrics, American Public Health Association, & National Resource Center for Health and Safety in Child Care and Early Education. (2011). Caring for our children: National health and safety performance standards; Guidelines for early care and education programs, (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association. Retrieved from http://www.healthybeveragesinchildcare.org/resources/CaringForOurChildren_NationalHealthandSafetyStandards.2011.pdf
American Nurses Association (ANA). (2012). ANA’s principles for delegation by registered nurses to unlicensed assistive personnel (UAP). Silver Spring, MD: Author.
Americans with Disabilities Amendment Act (ADAA) of 2008 (2009), 42 U.S.C. § 12101-12102. Retrieved from https://www.ada.gov/pubs/adastatute08.htm#12102
Blaakman, S.W., Cohen, A., Fagnano, M. & Halterman, J. S. (2014). Asthma medication adherence among urban teens: A qualitative analysis of barriers, facilitators and experiences with school-based care. Journal of Asthma, 51(5), 522-529. doi: 10.3109/02770903.2014.885041
Bobo, N. (2014). Principles for practice: Nursing delegation to unlicensed assistive personnel in the school setting. Silver Spring, MD: Author.
Cloete, L. (2015). Reducing medication errors in nursing practice. Nursing Standard, 29(20), 50-59.
FDA Consumer Health Information (2013). How to dispose of unused medicines. Retrieved from http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/ucm107163.pdf
Individuals with Disability Education Improvement Act (IDEIA). (2004). 20 U.S.C.1412 (a) (12) and (e) 34 C.F.R. 300.154. U.S. Government Printing Office (GPO) Electronic Code of Federal Regulations (e-CFR). Retrieved from https://legcounsel.house.gov/Comps/Individuals%20With%20Disabilities%20Education%20Act.pdf
Institute for Safe Medication Practices. (2012). Fewer school nurses leads to greater medication errors. ISMP Safe Medicine, 10(2). Retrieved from http://ismp.org/Newsletters/consumer/Issues/20120301.asp
Maughan, E. D. (2016, Spring). Building strong children: Why we need school nurses in schools. American Educator, 19-22. Retrieved from http://www.aft.org/sites/default/files/ae_spring2016school-nursing.pdf
McNaughton, D.B., Cowell, J., & Fogg, L. (2014). Adaptation and feasibility of a communication intervention for Mexican immigrant mothers and children in a school setting. The Journal of School Nursing, 30(2), 103-113. doi: 10.1177/1059840513487217
National Association of School Nurses (NASN). (2016). Framework for 21st century school nursing practice. NASN School Nurse, 31(1), 45-53. doi: 10.1177/1942602X15618644
National Coordinating Council for Medication Error Reporting and Prevention. (2007). Recommendations to reduce medication errors in non-healthcare settings. Retrieved from http://www.nccmerp.org/recommendations-reduce-medication-errors-non-health-care-settings
National Coordinating Council for Medication Error Reporting and Prevention. (2015). Recommendations to enhance accuracy of administration of medications. Retrieved from: http://www.nccmerp.org/recommendations-enhance-accuracy-administration-medications
Ryan, J.B., Katsiyannis, A., Losinski, M., Reid, R., & Ellis, C. (2014). Review of State Medication Policies/Guidelines Regarding Psychotropic Medications in Public Schools. Journal of Child and Family Studies, 23, 704-715. doi: 10.1007/s10826-013-9805-3
Section 504 of the Rehabilitation Act of 1973, 34 C.F.R. Part 104. U.S. Government Printing Office (GPO) Electronic Code of Federal Regulations (e-CFR). Retrieved from http://www.ecfr.gov/cgi-bin/text-idx?SID=4c6c861d1f28c519a11f862302cbbb1a&mc=true&node=pt34.1.104&rgn=div5
U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2011). Transmittal 77: CMS Manual system pub. 100-07 state operations provider certification. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R77SOMA.pdf
Van Cleave, J., Gortmaker, S.L., & Perrin, J.M. (2010). Dynamics of obesity and chronic health conditions among children and youth. Journal of American Medical Association, 303(7), 623-630. doi:10.1001/jama.2010.104
Acknowledgment of Authors:
Elizabeth Hinkson, MSN, RN, NCSN
Elaine Mauter, BSN, RN
Louise Wilson, MS, BSN, RN, NCSN
Annette Johansen, MEd, BSN, RN, NCSN
Erin D. Maughan, PhD, MS, RN, APHN-BC, FNASN, FAAN
Lindsey Minchella, MSN, RN, NCSN, FNASN
Bobbi Shanks, MS, BSN, RN, NCSN
Resources for Supporting Information:
NASN position statements:
The Role of the 21st Century School Nurse (June 2016)
Delegation, Nursing Delegation to Unlicensed Assistive Personnel in the School Setting (June 2014)
Unlicensed Assistive Personnel: Their Role on the School Health Services Team (January 2015)
School Nurse Workload: Staffing for Safe Care (January 2015)
AAP: Role of the School Nurse in Providing School Health Services (2016)
AAP: Guidance for the Administration of Medication in School (2009)
Revised: Revised: September 1997, June 2003, June 2011 (Amended January 2012), February 2017
Suggested citation: National Association of School Nurses. (2017). Medication administration in schools (Position Statement). Silver Spring, MD: Author.
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.