Medication Administration Medication Administration Practices in Schools and Practices in Schools and
DaycaresDaycares
Medication Administration Medication Administration Practices in Schools and Practices in Schools and
DaycaresDaycares Michael W. Kelly, PharmD, MSMichael W. Kelly, PharmD, MS
College of PharmacyCollege of PharmacyThe University of IowaThe University of Iowa
Why are medications used in schools?
• Treatment of children with chronic conditions– Mainstreaming of children with health
problems– Improved survival of children with complex
health conditions– Increasing use of medications in children
• Parents rely on schools to share responsibility of care
Who are using medications in schools?• ~46,500,000 children in K-12 in US• ~87,400 public schools in the US• ~13,000,000 children take medications
in the US in any 2 week time period• ~1,000,000 children took
methylphenidate in school in 1998• ~4-6% of children receive medication
on a typical school day
Why is this an issue?• Change in role of the school nurse
– ~57% of school districts have a nurse– Nurse to student ratio ~1:1,350– 2 of 3 most common school nurse interventions related to
medications– Use of unlicensed assistive personnel
• Multiple layers of authority– Federal law– State law– Local school district procedures– Individual school procedures– Professional guidelines
Why is this an issue?• Medication use is widespread in
schools• Administration of medicationsis
often carried out by non-licensed individuals
• Potential safety issues
Our study group• Ann Marie McCarthy• Nursing, Pharmacy, and Education
students• David Reed• Daniel Clay• Karen Farris
Study #1
“Medication Administration in the School Setting”– Purpose:
• To assess current practices of school nurses in administering medications in school
– Design:• Survey, Descriptive
– Subjects:• Random sample of 1,000 school nurses who were
members of the National Association of School Nurses
McCarthy AM, Kelly MW, Reed D. Journal of School Health. 2000;70:371-376
“Medication Administration in the School Setting”
• Survey– 62 primarily closed-ended questions across areas of
interest with space for comments• What medications are dispensed in schools?• Are guidelines for administering medications used by the
school nurse?• How widely are Unlicensed Assistive Personnel (UAP) used?• How is medication stored in the school?• Are dispensed medications documented?• What procedures are used in dispensing prescription and
non-prescription medications• What type of medication related consultation is used by
school nurses?
“Medication Administration in the School Setting”
• Results– 649 usable responses returned– Primarily female (99.7%)– Middle-aged (mean = 47.9)– 23 years experience as RN– 11 years as school nurse– Education level 50% BSN, 22% MS/MA
“Medication Administration in the School Setting”
• Number of children cared for– 0-1,000 50%– 1,000-2,000 28%
• Number of buildings responsible for– 1 building 41%– 2 buildings 31%– >3 buildings 26%
“Medication Administration in the School Setting”
• Medications dispensed– 5.6% of children receive medication during
a typical day• ADHD medications 3.3%• Nonprescription medications 1.5%• Asthma medications 1.1%• Analgesics 0.9%• Anti-seizure medications 0.6%
– Medications more common in elementary
“Medication Administration in the School Setting”
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Available Order
Creams
Tylenol
Cold Meds
Ibuprofen
GI
Aspirin
Nonprescription medications
“Medication Administration in the School Setting”
• Guidelines– Written guidelines 98%– State guidelines 92%
• Orders for administration of medication– Prescription medications
• Parent form 97%• Provider order 94%• Prescription label accepted 24%
– Non-prescription• Parent form 96%• Provider order 71%
“Medication Administration in the School Setting”
• Medication storage– Stored in locked cabinet in health office
80%– Secure container available in refrigerator
36%– Dispense from original pharmacy container
97%– Transfer medications to other container
23%
“Medication Administration in the School Setting”
• Personnel Dispensing Medications– 76% of these school nurses used UAPs– Description of UAPs
• Secretary 66%• Health Aide 40%• Teachers 38%• Other 38%• Parents 18%• Students 16%
“Medication Administration in the School Setting”
• Issues surrounding UAPs– Education
• Taught by school nurse 85%• Developed by school nurse 64%• Two hours in length or less 58%
– Are school nurses comfortable using UAPs?• Very or moderately comfortable 45%• Uncomfortable or very uncomfortable 33%• No response 18%
“Medication Administration in the School Setting”
• Self-administration– Self-administration allowed 76%
• Asthma inhalers and other asthma drugs• Insulin
– Junior/Senior High School75%
– Elementary 47%
– No Supervision 34%– Keep own medication 37%
“Medication Administration in the School Setting”
• Errors in Medication Administration– Medication error in the last year
49%– Types of errors
• Missed dose 80%• Not documented 30%• Overdose/double dose 23%• Administered, no authorization 21%• Wrong medication 20%
“Medication Administration in the School Setting”
Variable Estimated Effect
95% CI P value
Use of UAP 3.1 2.01-4.81 <0.001
# of Children 1.32 1.18-4.81 <0.001
Storage 0.71 0.49-1.02 =0.06
Education 1.56 1.10-2.22 <0.01
Self Management
1.13 0.75-1.70 =0.55
Contributing Factors to Medication Errors
“Medication Administration in the School Setting”
• Positives– Response rate– Medication use rate– Guidelines– Authorizations
• Negatives– Side effects not
documented– Storage– Delegation– Self administration– Errors
Clinical Implications•Need for consistent guidelines
•There are safety concerns
•Need for improved communication
Study #2
“Issues of Medication Administration and Control in Iowa Schools”– Purpose:
• To assess medication administration practices from the principals perspective
– Responsibility– Policies– Errors
– Design:• Cross sectional survey, Descriptive
Farris KB, McCarthy AM, Kelly MW, Clay D. Journal of School Health. 2003;73:331-337.
“Issues of Medication Administration and Control in Iowa Schools”
• Participants:– 850 randomly selected Iowa
principals (of 1,700)– Response rate 396/850 = 46.6%
• 75.5% Principals• 16.7% School nurses• 7.8% Other
– Schools of all grade levels
“Issues of Medication Administration and Control in Iowa Schools”
• Survey– 53 primarily closed end questions
• Based on previous survey• Sections
– Written guidelines– Medication administration processes and policies– Training requirements for medication
administration– Errors and causes of errors– Field trips– Demographics
“Issues of Medication Administration and Control in Iowa Schools”
• Who is ultimately responsible for medication administration?– Overall
• Principal 41%• School Nurse 34%• Unsure 13%• Other 4.3%
– On a day-to-day basis• School Nurse 76%• Other 24%
“Issues of Medication Administration and Control in Iowa Schools”
• School has written guidelines– Prescription Medication 97%– Non-prescription Medication 95%
• 22% of Schools use “Pill Counts”• Self-medication
– Allowed 50%• High schools more likely to allow
– Observed 83%– More common when a school nurse was available
• Missed dose was most common error
“Issues of Medication Administration and Control in Iowa Schools”
Never 1-2 Times >3 times Not sure
Med not supplied by parent 15.7 38.4 28.5 14.9Missed because of student 24.7 36.1 24.3 13.6Missed because of staff 47.7 32.5 5.8 12.4Wrong time 55.8 23.5 2.8 15.7Not documented 66.7 16.7 2.8 12.1Admin without authorization 84.8 3.8 0.8 9.3Given wrong medication 85.6 4.3 0 8.8Extra doses 86.6 3.3 0 9.6
Percent of Respondents Reporting Medication Errors in the Past Month
“Issues of Medication Administration and Control in Iowa Schools”
Disagree/ strongly disagree
Neither Agree/ strongly agree
Family does not communicate medications changes to school 18.2 17.4 55.0
Increased numbers of children onmedications
25.5 21.2 44.0
HCPs do not communicate changes in medications to school
30.3 26.5 33.6
Increased variety of medications prescribed to children 33.8 27.5 29.2
Inadequate staffing levels 42.9 19.2 29.1
Students are on same or similar medications 42.4 27.3 21.5
Percent of Respondents Reporting Reasons Contributing to Medication Errors
“Issues of Medication Administration and Control in Iowa Schools”
Disagree/ strongly disagree
Neither Agree/ strongly agree
Meds not labeled appropriately 64.4 13.9 12.6
Staff - not enough med and med administration training 61.6 21.0 9.4
Inconsistent day-to-day Process of med administration 68.2 14.9 7.8
Inconsistent documentation ofmedication administration 66.4 16.9 7.3
Students ask for wrong medication
71.4 17.7 2.3
Guidelines inadequate 69.5 16.2 1.8
Percent of Respondents Reporting Reasons Contributing to Medication Errors
“Issues of Medication Administration and Control in Iowa Schools”
Age of Student Stolen Medications Sold or Traded
Preschool & Elementary (n=56) 8.9 1.8Elementary only (n=97) 6.2 1.0Elementary & Middle School (n=20) 0 0Middle School only (n=62) 14.5 21.0Middle and High School (n=26) 11.5 15.4High School only (n=57) 14.0 15.8
Percent of Respondents Reporting Occurrences of Stolen, Sold or Traded Medication
“Issues of Medication Administration and Control in Iowa Schools”
• Clinical implications– Ultimate responsibility still unclear– Effects of self administration– Causes of medication errors– Diversion
Study #3
“Medication Distribution Trends in Schools”
• Purpose– To look at trends in medication use in
schools • Change from late 2000 to 2003• Change in medications used for ADHD• Change in administration time• Generate a list of medications administered
“Medication Distribution Trends
in Schools” • Methods
– Design• Anonymous mail survey, descriptive• Initial survey followed in 3 weeks by a second
– Subjects• A random sample of 1,000 school nurses who
were members of the National Association of School Nurses
“Medication Distribution Trends
in Schools” • Survey
– Subjects asked to supply information for the month that the survey was filled out and 3 years prior• Total number of students • Total number receiving prescription and
non-prescription medication• Number receiving individual agents for
the treatment of ADHD
“Medication Distribution Trends in Schools”
• Survey– Subjects asked to supply information
for the month the survey was filled out ONLY• Psychiatric conditions, asthma, seizure
and bladder/bowel management• List of all drugs administered in the
school
“Medication Distribution Trends in Schools”
• Survey– Assessed respondent perceptions on
• Change in methylphenidate use with release of Concerta®
• Any recent increase in immediate release methylphenidate
• Whether changes in medications are communicated to school
• Changes in the number of medication times
“Medication Distribution Trends in Schools”
• Results: Subjects– 338 Usable surveys returned
• 153 after first mailing• 185 after second mailing
– 154 had records for 2000 and 2003– 94% of the surveys were filled out by
school nurses• 83% held BSN/MSN/MPH degrees• Mean age 50 years, All female
“Medication Distribution Trends in Schools”
• Results: The Schools– 44 States and District of Columbia– 94% public– Level of student
• Elementary 198 (63%)• Middle/Junior High 99 (31%)• High School (26%)
“Medication Distribution Trends in Schools”
• The Students– Ethnic
• 66.8% White• 15.2% African-American• 12.8% Hispanic• 3.1% Asian • 1.3% American Indian/Alaska Native• 0.3% Native Hawaiian/Other Pacific IslanderResults
– Socioeconomic profile• 38.2% of schools had fewer than 25% of their students
in the free school lunch program • 21.2% of schools had 70-100% of their students in the
free school lunch program
Changes in Medications Administered, 2000 to 2003
2000Mean # of Students in a Typical Day (SD)
2003Mean # of Students in a Typical Day (SD)
In the designated school building
633.07 (516.46) (Range 0-5,200)
658.63 (541.29)(Range 0-5,100)
Receiving prescription medication *
18.09 (18.32)(Range 0-160)
8.72 (11.02)(Range 0-525)
ADHD Meds
Ritalin* 8.75 (8.26) 1.93 (2.60)
Adderal* 2.86 (3.73) 1.55 (2.65)
Concerta N/A 1.05 (4.02)
Dexedrine 0.87 (1.30) 0.29 (0.54)
Catapress 0.48 (1.01) 0.29 (0.71)
Welbutrin 0.23 (0.53) 0.14 (0.43)
Metadate 0.13 (0.59) 0.17 (0.53)
Receiving nonprescription medication
5.82 (9.68) 7.63 (23.98)
N= 177 schools with data for both years* p < .0001, Sign Rank Test
Prescription Medications, other than ADHD, administered in schools in 2003
Medication Number of
Schools*
Percent (%)
Asthma Treatments
Albuterol inhaler (Ventolin/Proventil) 260 87.0
Theophylline (TheoDur/SloBid) 7 2.3
Psychiatric Medications
Antipsychotics(Zyprexa, Seroquel, Geodon, Risperdal, Haldol)
75 24.1
SSRI Antidepressants (Paxil, Prozac, Zoloft, Celexa, Lexapro, Luvox)
49 15.8
Benzodiazepines (Valium, Xanax, Klonopin)
19 6.1
Tricyclic Antidepressants (amitriptyline, nortriptyline, imipramine, desipramine)
18 5.8
* Number of respondents varied from 200-311 for these items
Prescription Medications, other than ADHD, administered in schools in 2003 (Continued)
Medication Number of
Schools*
Percent (%)
Seizure Medications
Valproic acid, divalproex (Depakote) 69 22.2
Carbamazepine (Tegretol) 46 14.8
Phenytoin (Dilantin) 15 4.8
Bladder/Bowel Management
Oxybutinin (Ditropan), Tolterodine (Detrol), Polyethylene glycol (Miralax)
27 8.7
Nonprescription Medications
Analgesics (Aspirin, Acetaminophen, Ibuprofen) 207 68.3
Cough/cold products (Benadryl, Robitussin, Sudafed)
115 37.7
Gastrointestinal agents (Antacids, Zantac) 82 26.9
Alternative remedies (High dose vitamins, Herbals)
16 5.3* Number of respondents varied from 200-311 for these items
Psychotropic Medication Use
Medication Mean use per school
Range
SSRIs 0.49 0-34
Tricyclic ADs 0.09 0-3
Antipsychotics 0.45 0-13
Albuterol MDI 6.66 0-200
Albuterol MDI – PRN
1.26 0-64
Valproic Acid 0.74 0-100
Carbamazepine 0.23 0-8
Phenytoin 0.06 0-4
Nonprescription Medication Use
Nonprescription Medication Class
Mean use per school
Range
Analgesics 6.16 0-120
Cough/cold 1.12 0-40
GI agents 1.18 0-52
Alternative remedies 0.09 0-10
18 different Nonprescription medications are being given
Less common prescription medications administered in one or more schools grouped by
therapeutic class.
Therapeutic group with examples Unique
medication
named
Number of
students receiving
the medicatio
n
Gastrointestinal medicationsProton pump inhibitors, antacids, enzymes
20 49
Allergy/AsthmaAntihistamines, inhalers
19 37
Antibiotics/antiviralsCephalexin, amoxicillin
15 29
Antiseizure medicationsGabapentin, lamotrigine
11 39
Analgesics/migraine therapiesSumatriptan, aspirin/butalbital/caffeine
10 23
Hormonal/deficiency disordersSomatriptan, l-carnitine, levothyroxine, oral contraceptives
9 12
Renal disease/transplantationTacrolimus, Bicitra, PhosLo
8 8
Antianxiety agents/antipsychoticsBuspirone, mesoridazine
8 13
Less common prescription medications administered in one or more schools grouped by
therapeutic class.
Therapeutic group with examples Unique medicat
ion named
Number of
students receiving
the medicatio
n
Diabetic agentsMetformin, glucagon
5 63
CorticosteroidsPrednisone, presnisolone
5 7
Attention deficit disorder drugsMethylin, atomoxetine
4 43
AntidepressantsVenlafaxine, mirtazepine
3 6
AntihypertensivesPropranolol, bumetanide
2 5
Epinephrine injectionEpiPen
1 27
OtherHydroxyurea, baclofen, modafinil
7 7
Total 128 368
Variety of Medications Administered
• 7 ADHD drugs• 28 Prescription drugs in lists provided• 8 Nonprescription drugs in lists
provided• 128 “Other” prescription medications• 20 “Other” nonprescription medications
Total = 191 unique agents
Patterns of Medication Administration
• High school students– Administered fewer medications– Administered fewer ADHD medications– Administered more nonprescription meds
• Elementary students– Administered more asthma medications
Patterns of Medication Administration
• Small schools (<365 children)– Administered more medications– Administered more ADHD medications– Administered more Asthma medications
• Higher socioeconomic schools– Administered fewer medications– Administered fewer ADHD medications– Administered more nonprescription meds
Patterns of Medication Administration
• No difference across geographic region
• Children in private schools (n=17) were more likely to be given nonprescription medications
Percent of School Nurses Reporting Times Medications are Administered in Schools In 2003
0102030405060708090
7-8a
m
8-9a
m
9-10
am
10-1
1am
11-1
2pm
12-1
pm
1-2p
m
2-3p
m
3-4p
m
%
Results
• Perceptions– Is there a decrease in methylphenidate
administration?• 91% Agree or Strongly agree
– Is there a recent increase in the use of immediate release methylphenidate?
• 21% Agree or Strongly agree– Is failure to communicate medication changes a
problem?• 53% Agree or Strongly agree
– Has there been an increase in the number of administration times?
• 28% say YES
Limitations
• Sampling school nurses is convenient but misses schools without nurses
• Low response rate– Botched mailing– Lack of good records
Conclusions
– School nurses are responsible for more students
– Prescription medication administration is decreasing• ADHD medications in particular• Accompanied by an increase in the variety
– Nonprescription medication administration is increasing
– Medications administered throughout the day– Record keeping may be a problem
Recommendations• Schools must identify reliable sources of drug
information• Nurses need to share their expertise with less
trained assistants• Schools should review policies to identify ways to
increase information from families and health providers
• Physicians need to be aware of the complexity of medication use in the schools and act to reduce it
• Pharmacists can provide convenient dosages and containers and assure school is receiving relevant drug information
Future Research
• Measurement of the medication administration process
• Refinement and standardization of guidelines
• Quantify the impact of medication errors in schools