Chapter 6

Medication Administration in the School Setting

This chapter provides guidance for safely managing and administering medications in the school setting, including procedures, documentation, storage, and staff responsibilities.

Disclaimer

This section of the New Mexico School Health Manual provides guidance to schools based upon national standards of care, evidence-based practice, and state and federal statutes and regulations. The information contained in the New Mexico School Health Manual regarding medication administration in a school setting is intended to serve as guidance and to assist in developing and revising policies and procedures. It is not intended as legal advice. In the state of New Mexico, licensed nurses must have a provider authorization to administer any medication, including an over-the-counter (OTC) medications.

Introduction

Many school-aged children and adolescents with significant medical conditions can attend school due to advances in medical treatments and medications. As a result, there has been a dramatic increase in the range of medications used in schools, making the medication administration process more complex. Schools are accountable to provide safe, legal, and appropriate care for students and provide the environment to promote health and well-being for optimum student learning, performance, and attendance.

For additional information on medication administration in the school setting, refer to the National Association of School Nurses' School Nursing Evidence-based Clinical Practice Guideline. See Carr, B. & DuChateau, T. (2021). Medication administration in schools implementation toolkit. Accessed July 13, 2022, https://learn.nasn.org/courses/36927.

Definitions for Medication Administration

Federal and state laws, regulations, and rules exist regarding the administration and prescribing of medications. It is imperative for school personnel to understand the definitions of each.

Assignment of nursing activity: this involves appointing or designating another licensed nurse or assistive personnel that is consistent with his/her scope of practice (licensed person) or role description (unlicensed person).

Clinical Judgement: a cognitive process, by a licensed professional, that takes education, experience, current primary literature, and current standards of practice into consideration when drawing conclusions and reaching decisions.

Controlled Substance: a drug or substance listed in schedules I through V of the Controlled Substances Act or regulations adopted.

Delegation: the transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation.

Dispense: the evaluation and implementation of a prescription, including the preparation and delivery of a drug or device to a patient or patient's agent in a suitable container, appropriately labeled for subsequent administration to or use by a patient.

Distribute: the delivery of a drug or device other than by administering, such as the sale, purchase, trade, delivery, handling, storage, or receipt of a product.

In loco parentis: “in place of a parent,” or “instead of a parent,” this refers to situations in which someone other than a biological parent takes on the role of parent to a minor child without formally adopting the child. This situation applies to legal guardians, stepparents, grandparents, and other situations in which an individual has taken on parental duties.

Medication: articles intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease; and articles (other than food) intended to affect the structure or any function of the human body.

Medication Administration: the direct application of medications by injection, inhalation, ingestion, or any other means to an individual receiving services by (i) persons legally permitted to administer medications or (ii) the individual at the direction and in the presence of persons legally permitted to administer medications. The direct application of a drug to the body of a patient or research subject by injection, inhalation, ingestion or any other means as a result of an order of a licensed practitioner.

Medication Error: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems. These may include prescribing, order communication, product labeling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.

Nursing Assessment: analysis and synthesis of data performed by a Registered Nurse used to establish a health status baseline and plan of care, and to address changes in a patient's condition.

Nursing Competency: competency in nursing is the ability to perform skillfully and proficiently the role of the licensee. The role encompasses essential knowledge, judgment, attitudes, values, skills, and abilities, which are varied in range and complexity. Competency is a dynamic concept and is based on educational training, preparation, and expertise.

Nursing Practice Act: a New Mexico statute which governs the regulations and licensing of nurses or certification of hemodialysis technicians/medication aides and training programs thereof.

Patient Safety: the prevention of health care errors and the elimination or mitigation of patient injury caused by health care errors.

Prescribe: to issue an order, either directly from the prescriber to the pharmacist or indirectly by means of a written order signed by the prescriber, bearing the name and address of the prescriber, license classification, the name and address of the patient, the name of the drug prescribed, direction for use and the date of issue.

Prescriber: a licensed practitioner who generates a prescription order and assumes responsibility for the content of the prescription.

Repackage: repackaging or otherwise changing the container, wrapper, or labeling to further the distribution of a prescription drug excluding that completed by the pharmacists responsible for dispensing product to the patient.

Self-Administration: an individual manages and takes his or her own medication. They identify his or her medication and the times and methods of administration placing the medication internally or externally on his or her own body without staff assistance. They must have a written order from a physician and are able to safely maintain the medication without supervision.

Standing Orders: written authorization for nurses and other members of the health care team to complete certain clinical tasks without first obtaining a patient-specific provider order.

Supervision/Direction: the initial verification of a person’s knowledge and skills in the performance of a specific function or activity followed by periodic observation, direction, and evaluation of that person’s knowledge and skills as related to the specific functions or activity.

Routine medication: a medication for which the frequency of administration, amount, strength, and method of administration are specifically fixed as determined by the health care provider authorized by the state to prescribe medications. Routine does not include medications for which the time of administration, the amount, the strength of dosage, the method of administration, or the reason for administration is left to judgment or discretion.

Unlicensed Assistive Personnel (UAP): individuals trained to function in an assistive role to nurses in the provision of patient care, as delegated by and under the supervision of the registered nurse.

Considerations for Medication Administration in the School Setting

To protect from liability, any educational staff involved in medication administration in a school setting must be knowledgeable of laws and best practices involving school medication administration. Remember, in the state of New Mexico, licensed nurses must have a provider authorization to administer any medication, including OTC medications. To promote student safety, schools must provide for safe medication administration with guidelines, policies, and procedures that are not in conflict with state and federal laws, standards of medicine, pharmacy, and nursing practice. Also, they need to have enough staff trained in safe medication administration.

Optimally, all student medications should be administered at home by a knowledgeable and responsible caregiver. When that is not possible, administration by a School Nurse is an option. School nurses can identify and address issues that may affect management of acute and chronic health conditions, such as environmental factors and socioeconomic challenges, including obstacles to obtaining medications and delivery of medication to the school. The decision to delegate medication administration to Unlicensed Assistive Personnel (UAP) rests solely with the registered nurse providing services to the student. If, in the opinion of the School Nurse, the UAP is not competent, or is unwilling to carry out the task of administering medication, the School Nurse is not required to delegate the task to the UAP.

However, New Mexico schools are diverse, ranging from private to parochial to public charter, and campuses within local school districts also vary in their professional resources to support and oversee medication administration. Many schools have limited nursing services, perhaps for only several hours per week, or nurses may cover multiple schools with large geographical distances between the schools. These situations may create challenges. In certain situations, medication administration by school personnel other than a registered nurse, or by those who have not received delegation by a registered nurse, could be construed as practicing nursing without a license and subject to criminal and civil penalty as defined in the New Mexico Nurse Practice Act (NMSA § 61-3-30).

School districts and public charter, private, or parochial schools receiving federal funding are required to provide a Free and Appropriate Public Education (FAPE) (US Department of Education, 2020). Students who qualify and have an Individualized Educational Plan (IEP) may also have a supplemental Individualized Health Care Plan (IHCP). The registered nurse is the only school professional with the license and standard of practice who can develop the Individualized Healthcare Plan (IHP). This may contain medication administration which is delegated to unlicensed assistive personnel.

All students must have an up-to-date emergency contact form on file. It is recommended that districts and schools consider using the Emergency Medication Authorization form provided by the NMDOH and the NMPED. This form is a multi-use form that supports emergency contact, emergency transfer, and parent disclosures as required under statue.

References

Recommendations for School Board Policies, Procedures, and Protocols

Public school districts, public charter schools, private, and parochial schools should have a written, board-approved medication administration policy that addresses the following:

  • Approval to administer medications in the school setting.
  • Defined school personnel permitted to administer medications, such as a registered nurse, delegated to non-licensed personnel by a registered nurse.
  • Approval for delegation of medication or type of medication by a registered nurse.
  • Approved authorization form(s) to administer prescription medications. Remember, in the state of New Mexico, licensed nurses must have a provider authorization to administer any medication, including an OTC medication.
  • Confidentiality addressing HIPAA and FERPA.
  • Training of personnel.
  • Personnel permitted to accept medication(s), storage, and handling.
  • Documentation and record keeping.
  • Medication error procedures.
  • Self-carried and self-administration of medications. Self-carry requires PCP order and evaluation of ability.
  • Over-the-counter medications (OTC). Remember, in the state of New Mexico, licensed nurses must have a provider authorization to administer any medication, including an OTC medication.
  • Homeopathic/herbal, essential oils, and aromatherapy (see above).
  • Field trips/school sanctioned events.
  • "Off label" medication use.
  • US Food and Drug Agency (FDA)-approved investigational medications and samples.

Medication administration policies and procedures should be developed to meet professional standards of practice as established by the NM Boards of Nursing, Medical and Pharmacy, and state Departments of Health and Education when appropriate. There are no legal restrictions preventing a parent/guardian from administering a medication in the school setting to his/her child. However, school policy should include the parameters under which this activity may take place.

Common Types of Medications in the School Setting

There are several types and categories of medications. Each has unique medication administration considerations that are addressed in this chapter.

Prescription medications can either be controlled (e.g., Ritalin, oxycodone) or non-controlled (e.g., insulin, albuterol inhalers) and are always written by a licensed provider. An emergency medication is usually a prescribed medication and is not usually a controlled substance. Emergency medications can be either a self-carry and self-administered medication, or stored stock medication that is used when a patient-specific emergency medication is not available.

Routine medications are usually administered daily or several times per day and should generally have a predictable outcome. Routine medications are either prescribed or an over-the-counter medication. An Over-the-Counter (OTC) medication is a medication that can be purchased without a provider’s written prescription. These are usually taken and administered on an as-needed basis. Note that OTC medications may sometimes be prescribed by a provider (this may occur, for example, so that health care insurance will cover the cost). Remember, in the state of New Mexico, licensed nurses must have a provider authorization to administer any medication, including an OTC medication.

Complementary and Integrative Therapies (CAM) are a group of diverse medical and health care systems, practices, and products that are not presently considered part of conventional Western medicine. CAM is also known as integrative or alternative therapies.

Emergency Medications in the School Setting

Students with conditions such as diabetes, seizures, life-threatening allergies, or asthma need immediate access to emergency medications. While schools are not expected to function as emergency care centers, the ability to support students until emergency medical services arrive is important. The most common emergency medications administered in the school setting are epinephrine auto injectors, albuterol, glucagon, seizure medications, and oxygen. All staff should be trained in the identification of emergent symptoms necessitating the need for the emergency medications, deployment of school emergency call system, location of emergency medications, evacuation, and transportation plans.

Emergency medications can either be specifically prescribed for a student by a provider (epinephrine, glucagon, albuterol, Diastat, midazolam, Solumedrol, insulin, oxygen) or the school district may consider implementing a special emergency medication program supported by the NMDOH (Emergency albuterol and epinephrine, oxygen, Narcan). Each have requirements and special considerations. Remember, in the state of New Mexico, licensed nurses must have a provider authorization to administer any medication, including an OTC medication.

Template Forms for Emergency Medications

Self-Administration of Emergency Medications

New Mexico law (NMAC § 6.12.2) requires all schools, whether public or private, to have school policies to allow any student in grades K-12 to carry and self-administer provider-prescribed asthma and anaphylaxis emergency medication during the school day, school sponsored activities, before and after school care (if on school property), and in transit to and from school or a school-sponsored event, if the following conditions are met:

  • A health care practitioner has prescribed the medication for use by the student during school hours and instructed the student in the correct and responsible use of the medication; and,
  • The student has demonstrated the skill level necessary to use the medication and any device that is necessary to administer such medication as prescribed by the health care practitioner (or such practitioner’s designee) and the School Nurse or other school official who is a public education department-licensed health care provider; and,
  • The School Nurse (if available), with the health care practitioner, formulates a written treatment plan for managing asthma or anaphylaxis episodes of the student, and for medication use by the student during school hours; and,
  • The school has, in writing, informed the parent or guardian of the student that the school, including its employees and agents, is to incur no liability because of any injury arising from the self-administration of medication pursuant to this section; and
  • The student’s parent or guardian has completed and submitted to the school any written documentation required by the school, including the statement required the treatment plan formulated; and,
  • A signed statement from the parent or guardian of the student acknowledging that, notwithstanding any provision of state law to the contrary, the school (including its employees and agents) is to incur no liability as a result of any injury arising from such self-administration of medication, and the parent or guardian will indemnify and hold harmless the school (including its employees and agents) against any claim arising out of such self-administration of medication.

Immediate access to emergency medications is critical and vital to the effectiveness of these life-saving interventions. The school must ensure that back-up medication, if provided by a student’s parent or guardian, be kept at the student’s school in a location easily accessible to the student in the event of an asthma or anaphylaxis emergency. It is important for each student to have an Emergency Care Plan (ECP), and if appropriate, an Individualized Health Plan (IHP) to delineate acceptable and safe emergency intervention procedures and parameters. Such plans require parental signature and signature of responsible school staff for maintenance of student confidentiality.

Emergency Medications in the Schools Act (Stock Emergency Medication Program)

If there is adequate supply or availability of emergency response and the school is in proximity for response through the 911 system, the most appropriate primary emergency response may be to call 911 rather than having a stock emergency medication program. It is recommended that discussion between school district administration, school health personnel, and the local 911 responders take place to determine the feasibility of this option as policy.

The New Mexico Emergency Medications in Schools is a voluntary program. The program provides access to stock emergency medications (albuterol and/or epinephrine via auto injector), which means there are not prescriptions for individual students. Whenever either medication is used, the Emergency Medical System (EMS) must still be activated. And an adverse event form must be filled out and sent to the regional School Health Advocate via the new database Smartsheet: (NMDOH Adverse Event Form for Schools).

School district, public charter, parochial, or private schools considering implementation of the Emergency Medications in Schools Program should review Rules and Recommendations to School Districts for Stock Emergency Medications in Schools (see below links). There are special requirements for both the Stock Emergency Albuterol and Epinephrine program:

For further information and technical assistance, contact the NMDOH School Health Advocate assigned to the region.

Naloxone (Narcan) in the Schools Program

Opioid overdose in the US is a public health crisis. Schools may benefit from the ability to have a substance-abuse prevention program and harm-reduction program to include naloxone on school grounds.

Naloxone is the generic name for the medication and Narcan is a commonly available brand of naloxone. The medication is an opioid antagonist used to reverse overdoses. Availability and use of naloxone is complicated by the intersection of state laws that allow individuals to obtain and carry naloxone, the status of naloxone as a prescription medication, Board of Pharmacy regulations, and health-care professional standards.

In New Mexico, a person may possess an opioid antagonist, regardless of whether the person holds a prescription for the opioid antagonist (NMSA § 1978, 24-23-1.A), and a person may administer an opioid antagonist to another person if the person in good faith believes the other person is experiencing a drug overdose and acts with reasonable care in administering the drug to the other person (NMSA § 1978, 24-23-1.E). Therefore, unless prevented by school policy, individuals in the school who obtain naloxone could carry and administer the medication.

Although an individual would not be subject to “professional disciplinary action as a result of the possession, administration, or distribution” of an opioid antagonist, NMDOH provides a standing order to support school nurses as, in the state of New Mexico, licensed nurses must have a provider authorization to administer any medication, including an OTC medication. (See Chapter 15 for the Narcan Standing Order.)

A New Mexico pharmacy license is not required for schools to possess and store naloxone unless the school district is acting or serving as a distribution site. To ensure safety and efficacy, NMDOH recommends that schools adhere to medication storage room standards (e.g., inventory, documentation, temperature, security, monitoring, disposal). If Naloxone is ever administered on the school premises, an NMDOH Adverse Event Form for Schools should be submitted to your regional School Health Advocate.

Schools may obtain naloxone from any entity that is willing to provide it to the school, whether by donation or purchase. Individual or group donors may pay for medication, but it must be provided directly to the school from an entity licensed to store or distribute medications (i.e., community members may not donate their own personal medication). For further information and technical assistance, contact the NMDOH School Health Advocate assigned to the region.

Emergency Diabetes Medication

New Mexico Statute (NMSA §6.12.8.1 et seq) requires all schools, whether public or private, to have school policies to allow any student in grades K-12 to carry and self-administer provider prescribed diabetes management medications, supplies, and equipment during the school day, school sponsored activity, before and after school care if on school property, in transit to and from school or school sponsored events. School personnel who in good faith report any known or suspected violation of the school discipline policy or in good faith attempt to enforce the policy shall not be held liable for any civil damages. The NMPED is the state agency that is authorized in overseeing policy related to diabetes management in the school setting. Each school district or school must file an annual report with the NMPED. For requirements and additional information please click here (School health resources. [2022, March 29]. New Mexico Public Education Department. Retrieved July 13, 2022, from https://webnew.ped.state.nm.us/bureaus/safe-healthy-schools/school-health-resources/).

Additional resources may be found in the Guide to Helping the Student with DM Succeed and provide the necessary resources and tools to assist schools in managing diabetes in the school setting. See: American Diabetes Association. (2020, May). Helping the student with diabetes succeed: A guide for school personnel. Retrieved July 13, 2022, from https://www.diabetes.org/sites/default/files/2020-06/SchoolguidepdfMay2020.pdf).

The school board policy should address the following:

  • Maintenance of student confidentiality.
  • Training of personnel; there are three tier requirements for training:
    • Level one training is for all school staff and provides an overview of diabetes, signs and symptoms of hypoglycemia and hyperglycemia, and emergency response. It is designed for all staff members who has supervision/care of diabetic student at any time during the school day or after school event.
    • Level two training provides more in-depth training and is designed for any school staff member that may be assisting the student in the day-to-day management of diabetes.
    • Level three training is designed for a staff member that will be directly providing diabetes care in the school setting.
  • Requirement of a written plan of care signed by an appropriate health-care provider authorizing and acknowledging that appropriate student instruction in the correct and responsible use of the medication and associated devices has been done.
  • Requirement that a written health care provider treatment plan be submitted and signed by the parent/guardian and be renewed by the parent or guardian each subsequent school year.
  • Procedure for any back-up medication kept at the school, if provided by a student’s parent or guardian, to ensure that they are easily accessible and safely stored in the event of an emergency.
  • The student has demonstrated to the health care provider, School Nurse, or other school official the skill level necessary to use the medication and any device that is necessary to administer the medication as prescribed.
  • The school must document and maintain records of this capacity.
  • All school staff are to be adequately trained in diabetes awareness, signs and symptoms of hypoglycemia and hyperglycemia and the associated emergency response

Self-Carrying and Self-Administration of Non-Emergency Medications

It is important to have a written, school-board-approved policy that clearly states whether students may self-carry and/or-self-administer non-emergency medications (e.g., ibuprofen/acetaminophen) defined under New Mexico statues. The written board policy should include the following:

  • Only secondary-level (6th through 12th) students are permitted to self-carry a supply of medication, to be carried with written approval by parent/guardian and with a provider order to self-carry/self-administer the medication.
  • However, the NMDOH recommends all non-emergency medications to be stored in a secure area, such as the health office, to promote medication administration safety, since there will be observation by an educational staff member.
  • Personnel assigned to observe self-administered medications in the health office must take the NMDOH-sponsored Health Assistant Training to enhance knowledge of safe medication administration, medication storage and handling, medication disposal, applicable laws and regulations, and best practices in medication administration.
  • Ensure that there are other trained staff to perform this function in case of an absence.
  • Controlled substance medications are to be stored securely per the US Drug Enforcement Agency (DEA) guidelines and must not be self-carried due to the risk of theft and diversion.

Self-administration instructions are to be provided by the parent/guardian or health care provider, and if a school nurse is employed by the school, the school nurse is to conduct and provide a written assessment to evaluate the student’s ability to perform safe and accurate self-administration. Below are considerations for school policy regarding self-carry and self-administration of medication:

  • Has the student received instruction and stated understanding of the responsible way to self-carry and self-administer the medication, including that the medications are not to be shared?
  • Is there a medication order stating that the student is qualified and/or able to self-carry and self-administer the medication?
  • Is there written parental consent for self-carry and self-administration?
  • What medication will the student be allowed to carry and administer?
  • Does the medication require refrigeration or security?
  • Is there a need for notification of appropriate team members (such as teachers, principals, support persons) of self-testing or self-administration of medication?
  • Does staff need training to support the student?
  • Recognition by student and family that the ability to self-carry/self-administered may be revoked if medication policies are abused or ignored.

Template Forms for Self-carry and Self-administration

Considerations for Over-the-Counter (OTC) Medications.

Remember, in the state of New Mexico, licensed nurses must have a provider authorization to administer any medication, including an OTC medication. Due to this requirement, the Regional Health Officers (RHOs) with the NMDOH have provided standing orders for some OTC medications. (Please, see Chapter 15). Benefits to allowing OTC medications include keeping students in school and providing symptom relief. Risks include possible side effects from the medication, masking of underlying serious health conditions, or potential liability for schools/districts. If a school or district chooses to allow OTC medications to be administered on campus, multiple factors need to be considered. Here are a few of the factors (not to exclude other considerations):

  1. Will need either a patient specific individualized order or implementation with board approved policy of NMDOH Standing Orders
  2. Should not be used for longer than 3 consecutive days without referral to PCP for evaluation. (This should be true whether using a patient specific order or the NMDOH Standing Orders as there may be an underlying condition causing the symptoms)
  3. Each LEA will need to determine if a student can self-carry/self-administer the OTC medication under adult supervision as well as having a provider order for self-carry. (see above Self-Carry section)
  4. School board policy to address:
    1. Whether OTCs are permitted
    2. Whether students can self-carry/administer
    3. Which school personnel are authorized to administer
    4. Whether the district or school is permitted to purchase, or if a parent or guardian is required to purchase and bring OTC medication into the school
  5. If purchased by a parent/guardian:
    1. Encourage single dose packaged.
    2. An adult should bring the OTC medication to the health office unopened and labeled with the student’s name.
    3. Assigned school personnel to log in and take inventory of the type, amount, and reason for use with the parent/guardian.
    4. Assigned school personnel to ensure parent/guardian signs and dates authorization form
  1. If purchased by the school:
    1. Use single-unit dose OTC (dispensing from a bulk container can lead to contamination and is a Board of Pharmacy violation).
    2. purchase for all age ranges for the student population enrolled and follow manufacture’s dosing recommendations on packaging.

See this additional information from the American Academy of Pediatrics. Guidance for the administration of medication in school. (2020). https://publications.aap.org/aapbooks/book/560/chapter-abstract/5814080/Guidance-for-the-Administration-of-Medication.

Considerations for Psychotropic Medications

Medications prescribed for attention deficit/hyperactivity disorder (ADHD), depression, anxiety, and other mood disorders are known as psychotropic medications. These medications are prescribed by a medical provider, some may be controlled substances that are regulated under the Controlled Substance Act and will have special prescribing, storage and handling, and destruction requirements. A significant number of psychotropic medications have not been approved by the Federal Drug Enforcement Agency for use with children and adolescents. However, the most common administered in the school setting are:

  • Antidepressants.
  • Antipsychotic.
  • ADHD.
  • Mood Stabilizers.

Many of the psychotropic medications will have medication side effects to varying degrees. The most common side effects are:

  • Anticholinergic effects (ACEs): dry mouth, blurred vision, constipation, and urinary hesitancy. These effects result from the suppressive action of antipsychotic and antidepressant medications on the pyramidal nerve pathways.
  • Neuroleptic malignant syndrome: high fever, muscle rigidity, and fluctuating levels of functioning.
  • Orthostatic hypotension: a sudden drop in blood pressure that occurs when rising from a lying or sitting position to a standing one, accompanied by dizziness, lightheadedness, weakness, and unsteady walk.
  • Tachycardia: an increase in heart rate resulting from adverse effects of antidepressant medications.

For additional reading, refer to Students and Psychotropic Medications: The School's Role. (2016). Center for Mental Health in Schools at UCLA. Retrieved July 13, 2022, from http://smhp.psych.ucla.edu/pdfdocs/psymeds/med1.pdf.

Considerations for Complementary and Integrative Therapies (CAM)

Medical doctors (MDs) and doctors of osteopathy (DOs) have prescriptive privileges in the state of New Mexico. In recent years the NM State Legislature has granted limited prescriptive privileges to the following health care providers.

    • Nurse Practitioners (CNP).
    • Nurse Midwives (CNM).
    • Physician Assistants (PA).
    • Rural Anesthetists.
    • Nurse Specialists.
    • Doctors of Oriental Medicine (DOM).
    • Chiropractors (DC).

CAM is also known as integrative or alternative therapies. NCCAM defines Complementary Alternative Medicine (CAM) as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional Western medicine. The National Center for Complementary and Alternative Medicine (NCCAM) is part of the National Institutes of Health (NIH) and conducts research on the efficacy of complementary medicine and is a resource clearinghouse for CAM therapies and products.

All providers with prescriptive privileges are expected to meet the same standards when prescribing medication for administration in the school setting, as in any other situation. Below are examples of CAM being used in the school setting:

  • Herbal products.
  • Essential oils.
  • Dietary supplements.
  • CBD.
  • Medical cannabis.

All school districts and schools should have up-to-date School Board Policy and Procedures outlining the following:

  • Meet professional standards of practice for safe medication administration, which should be followed consistently.
  • Follow state board nursing regulations. It is recommended that school nurses not administer herbal supplements to students at school and that nurses prohibit school personnel from administering herbal medication, nutritional supplements, or essential oils.
  • Students should not be allowed to self-carry CAM.

More contemporary CAMs used in the school setting are CBD and medical cannabis.

Medical Cannabis

New Mexico State law, NMSA § 22-33-5, addresses the access and use of medical cannabis in public schools. Local school boards and governing bodies of charter schools must adopt policies and procedures to authorize possession, storage, and administration of medical cannabis by parents, legal guardians, or designated school personnel to qualified students. The state agency with authority to oversee school-based medical cannabis policy is the NMPED.

Resources

School board polices should address issues such as:

  • School personnel who are permitted to administer medical cannabis to qualified students. Currently, Licensed School Nurses are not permitted to administer cannabis.
  • Reasonable parameters for administration and use of medical cannabis.
  • The school location where administration and use are authorized.
  • Policy on disciplinary actions toward non-authorized student possession, use, distribution, and sale of cannabis products, inconsistent with law and regulations.

New Mexico Regulations (NMAC § 6.12.10.8) provide additional detail on policies for medical cannabis:

  • Schools are not required to authorize the use of, nor administer, medical cannabis if the school or school district reasonably determines that it would lose federal funding because of such a policy. Parent or guardian may be able to appeal.
  • Schools may not discipline a qualified student on the basis of requiring medical cannabis as a reasonable accommodation, deny eligibility to attend school or school-sponsored activity, or discipline a school employee who refuses to administer medical cannabis.
  • Schools may not permit a student to possess, store, or self-administer medical cannabis in a school setting.
  • Schools should have a written treatment plan for the administration of medical cannabis in place that includes a copy of the qualified student’s written certification under the Lynn and Erin Compassionate Use Act and a written statement from the parent or guardian releasing the school and school personnel from liability.

Considerations for Medication Administration in the School Setting

To ensure that students receive support at school under optimal protection, the following guidelines should be followed and addressed in the school or school district’s policy, procedures, and student handbook:

  • Approved school board policy and procedures for medication administration which are reviewed annually and updated as needed.
  • Medication-administration policies are best developed, supervised, and guided by a School Nurse.
  • Administer medications only if there is a current-school-year medication-administration authorization form signed by the student’s primary health care provider and parent/guardian. This form is to be updated as needed by the primary care provider as medications change, as well as each school year (even if there have been no changes).
  • The signed medication authorization form should be reviewed and approved by the School Nurse, prior to any medication administration or delegation.
  • The medication label should not be used to determine or verify route, dose, or frequency – use the most current provider medical authorization/order.
  • Changes in the dosage of the medication require a written provider authorization/order.
  • Unused medication should be disposed of or returned according to the school board-approved policy and procedure for medication administration.
  • The first dose of a newly prescribed medication shall be given at home.
  • Discontinued medication must have a written order by a physician stating discontinuance.
  • Prescription medication must be in a pharmacy-provided container, with a current prescription label to include:
    • student’s name.
    • medication.
    • strength and prescribed dosage.
    • route of administration.
    • time-schedule of administration.
    • prescribing health-care provider.
    • date of prescription.

Considerations for Use of New Mexico Department of Health Standing Orders

The New Mexico Department of Health issues medical standing orders. Standing orders are non-patient-specific medical orders that are issued to provide for a certain population. The authority to develop and issue the NMDOH Standing orders are through the Public Health Division’s Regional Health Officers and are used by schools that employ school nurses unless otherwise authorized for non-nursing use. See Chapter 15 for current Standing Orders.

When giving medications, best practice is the 8 Rights of Medication Administration. Follow these steps every time a medication is administered. Check to ensure you have the:

  1. Right patient.
    • Ask the student to identify using two identifiers (name and date of birth).
    • Student may have an adult proxy to provide identification if unable to provide self-identification (e.g., teacher, classroom assistant).
  2. Right medication.
    • Check the medication label and cross-reference to the signed written medical authorization or provider order.
    • Do not administer if medication label or prescriptions do not match the written authorization or provide order.
    • Teach/ask the student what medication he/she is taking.
  3. Right dose.
    • Check the medication label (for OTC) or written medical authorization/provider order for dose.
    • Confirm appropriateness of the dose using a current drug reference if needed (nurses only).
    • Teach/ask the student how many milligrams/milliliters, etc. he/she is taking.
  4. Right route.
    • Check the order for appropriateness of the route.
    • Use an appropriate measuring tool for administration.
    • Confirm the student can take or receive the medication by the ordered route.
    • Teach/ask the student how he/she takes the medication (e.g., by mouth, eye drops, etc.).
  5. Right time.
    • Check the frequency of the ordered medication.
    • Double-check that you are giving the ordered dose at the correct time.
    • Confirm when the last dose was given.
    • Teach/ask the student what time he/she takes their medication.
  6. Right documentation.
    • Document administration after giving the ordered medication.
    • Chart the time, route, and any other specific information as necessary.
    • Some school districts have the student co-sign with the person administering the medication.
  7. Right reason.
    • Confirm the rationale for the ordered medication. What is the student’s history? Why is he/she taking this medication?
    • Teach/ask the student why he/she is taking the medication (e.g., “keep me calm,” “help me focus,” “so I don’t have seizures”, etc.).
  8. Right response.
    • Make sure that the medication led to the desired effect.
    • If monitoring is required, be sure to document your monitoring of the student and any other nursing interventions that are applicable.
    • Ask the student how he/she feels after the medication has taken effect.

It is important for students to understand and assume as much responsibility as possible during medication administration. Consideration for this should be age-appropriateness and developmental level. By performing the 8 Rights of Medication Administration, and including the student in the process, the student learns the correct way to take medication and is an active participant in their health care.

Medication errors result if any of the Rights of Medication Administration are incorrectly applied or omitted. Please see the Rights of Medication Administration definition and Medication Administration Procedures section. Medication errors may also occur if controlled medications (e.g., Ritalin) are stolen or diverted. Medication errors often go undetected or unreported. Medication errors are three times more likely when unlicensed assistive personnel (UAP) administer medicines instead of a school nurse

The National Coordinating Council for Medication Error Reporting and Prevention has also developed these recommendations as guidance to non-health-care settings to help ensure protection of students who must depend on assistance for medication management in these settings. These recommendations apply to non-health-care settings regardless of whether licensed health professionals are involved in managing medications.

Recommendations for School Settings to Reduce Medication Error:

  • Request parents/guardians to inquire with the prescribing provider about whether a long-acting form of the student’s medication is available and appropriate for their child.
  • Where medications are stored and administered to individuals, written policies and procedures should address the acquisition of medications (e.g., from parents, caregivers).
  • Where medications are stored and administered, training should be provided to personnel with responsibilities related to medication management. The training should correspond to the written policies and procedures, and the person's scope of duties associated with medications.
  • Where controlled medications are stored and/or administered, safeguards should be in place to prevent and detect theft and diversion.
  • Encourage the reporting of medication errors to appropriate state and national medication error reporting programs. These medication error reports may be used to identify significant trends or patterns that can lead to improved quality and safety of health care, and to teach others how to prevent similar errors.

When a medication error occurs, evaluate possible causes to improve the facility's system for medication management and to prevent future errors.

Resources

  • Consumer Med Safety. (2012, May 7). Prevent medication errors. Retrieved July 13, 2022, from https://consumermedsafety.org/medication-safety-articles/item/550-fewer-school-nurses-leads-to-greater-medication-errors).
  • NCC MERP. (2007, February 27). Recommendations to reduce medication errors in non-health care settings. Retrieved July 13, 2022, from https://www.nccmerp.org/recommendations-reduce-medication-errors-non-health-care-settings.

Schools need to provide for the safe and appropriate storage of all medications ordered by a provider for individual children’s use at school. Storage of certain emergency drugs and non-prescription medications may also be necessary.

The following guidelines should be considered when developing a policy for storage of medications kept at school.

  • Medications should be stored in a locked cabinet in a secured area – ideally in a cool, dark place, unless otherwise indicated. An exception is self-administered medication that students have permission to keep in their possession. Controlled substances require special attention in the school district’s policies. FDA, DEA, and NM Pharmacy rules require that all controlled substances always be stored in a double-locked narcotic cabinet that is equipped with two separate locks and keys.
  • Controlled substance tracking by maintaining a daily pill count of all controlled medications stored at school is a best practice and recommended. When the medication is received in the health office, the amount should be documented by the School Nurse or her/his designee and the parent/guardian or another school employee, with both adults signing the documented count. The signed documentation that a student has received his/her daily dose can serve as the tracking log for any medication including controlled substances.
  • Medications, such as antibiotic liquids, may require refrigeration. The refrigerator should be in a secure area, which is not accessible to unauthorized individuals. The temperature should be checked daily when school is in session and should be maintained between 36- and 46-degrees Fahrenheit. Food should not be kept in the same refrigerator as medications.
  • Medications (prescription and over-the-counter) should be kept in original labeled containers provided by the dispensing pharmacy/provider or the manufacturer.
  • Exceptions to the above guidelines should be noted on the relevant student’s individualized health-care plan.

Recommendations for Field Trip Medications

Field trips often create challenging situations regarding those students who require medication administration. School district policy should address this issue from the standpoint that medications which cannot be self-administered require the services of the School Nurse or an adult, who is trained and assessed as competent by the PED-licensed School Nurse to administer the medication(s). It should be noted that the NM Nursing Practice Act Rules allow nurses to administer and (where appropriate) to delegate the administration of medications, but not to prescribe or dispense. Parental/guardian sign-off of all medication administration arrangements is recommended.

Same day field trips will require a separate single-dose field trip supply of medications, in an originally-labeled pharmacy container. Medications should be prepared by a pharmacist and brought to the school by the parent/guardian for the scheduled field trip. If a separate supply of medication in an originally-labeled pharmacy container is not available for same-day field trips, the School Nurse should use the originally-labeled pharmacy container being held at school. The School Nurse, or the adult who is trained and delegated the task of administering the medication, should return the originally-labeled pharmacy container to the authorizing PED-licensed nurse, and sign-off on the school’s daily medication log that the student received prescribed medication.

Extended field trips include those that begin before and/or extend beyond the duty day for school staff. For such field trips, the parent/guardian should be involved with school staff in planning for safe administration of his/her child’s medication during the field-trip day(s). It is also the parent/guardian's responsibility to provide all medications required during the field trip in an originally-labeled pharmacy container for the student; these medications should not come from the individual student's supply held at school. Parents can contact their pharmacy to have a separate "field trip"-labeled pharmacy container to provide nurse medication for field trips. It is the School Nurse's responsibility to collaborate with parents/guardians and trip chaperones and provide guidance regarding all medication issues for students on all field trips.

Medication Error/Incidence Report

A medication incident report form should be used to report medication errors and must be filled out every time a medication error occurs. Common errors include the following.

  • Wrong student.
  • Wrong medication.
  • Wrong dose.
  • Wrong route.
  • Wrong time.

All medication incident reports should be shared between the school nurse, the parent/guardian, and other appropriate school and health-care personnel according to school policy.

Any medication error that requires an ambulance to be called or requires the student to be transported to an emergency room or urgent care facility, is considered a significant event and must be reported to the NMDOH Regional Health Officer using the NMDOH Adverse Event Form for Schools.

The NM Poison Center (1-800-222-1222) may be used as a resource for medication errors.

Medication Administration Record and Documentation

Documentation of medication given at school should be part of the school’s written policy and practice for administering medications. Each dose of medication administered or witnessed by school staff should be documented on a medication log, in ink or electronically. This log becomes a permanent health record for parents and health-care providers and provides legal protection to those who assist with medications at school. It also helps ensure that students receive medications as prescribed, and it can help reduce medication errors. Any hand-written error should be corrected by drawing a single line through the error, recording the correct information, then initialing and dating the corrected entry, as with any medical record. PED-licensed school nurses, who maintain medication logs on computer software programs, should use strike-over to reflect the information was in error, then enter correct information that reflects when and by whom the error was corrected.

The medication log should contain the following information:

  • Student’s name.
  • Prescribed medication and dosage.
  • Schedule for medication administration.
  • Name(s) and signature(s)/initial(s) or electronic identification of individual(s) authorized and trained to supervise self-administration of medications.
  • Picture of the student for identification purposes (optional).

Unclaimed and Unused Medication Disposal

Parents/guardians should be informed that it is their responsibility to retrieve any unused doses of medication if the student is withdrawn from the school and/or at the end of the school year. The school should maintain a written policy to cover the following issues regarding those medications that are not retrieved.

  • Written communication should be sent to the parents/guardians prior to the end of the school year with notification that unused medications must be retrieved by a specified date. The same communication needs to occur for any student who withdraws during the school year.
  • Any medications not picked up by the designated date should be disposed of by the PED-licensed School Nurse in the presence of another school employee in a manner to prevent any possibility of further use of the medication. Environmental considerations should be kept in mind when disposing of unused medications. The FDA provides guidelines for safe disposal (see below).
  • The School Nurse and school employee in charge of the disposal of unused medications should document the name of the medication and amount disposed of along with the name of the student for which it was prescribed. Both individuals should sign the documentation.

Unused medications should not be released to the student regardless of age, even with parental/guardian consent.

Resources

  • FDA. (2021, April 21). Where and how to dispose of unused medicines. US Food and Drug Administration. Retrieved July 13, 2022, from https://www.fda.gov/consumers/consumer-updates/where-and-how-dispose-unused-medicines.

Primary Editor: Dr. Christopher Novak, MD & Crista Pierce, BA, RN, CLNC
Secondary Editors: Maricelda Pisana, BSN, RN & James Farmer, Director of OSAH

Resources and References

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