Medication Errors Abound at Schools

With more kids than ever taking medicine at school for chronic conditions such as asthma, diabetes and attention deficit hyperactivity disorder, a new study is raising questions about just how well they’re being served.

Half the school nurses who responded to a nationwide survey reported medication errors in the past year--most commonly missed doses, but also too-large doses or the wrong medicine.

“The incidence of medication errors is not acceptable,” the study concludes. “Ongoing efforts to develop national guidelines must continue.”

The University of Iowa nurses and pharmacists who conducted the study in the summer of 1999 sought to determine how often medication errors arise and who’s administering those medications. The answers are especially relevant at a time when some school systems are being asked to deliver more and more health-related care and screening.

The study results, based on survey responses from 649 of 1,000 school nurses randomly selected from the ranks of the National Assn. of School Nurses, suggest that school systems may be giving too little attention to health, an important aspect of kids’ welfare.

“It’s a huge issue. The school nurses are out there almost on their own,” said lead author Ann Marie McCarthy, an associate nursing professor at the Iowa College of Nursing.

Although other studies have examined school health programs more broadly, McCarthy said hers was one of very few--if any--to focus specifically on medications given at schools.

“The context is that there simply are more children in school with health conditions requiring medication now than in the past,” she said, citing recent increases in the number of children being medicated for ADHD.

“Children with complex health care needs used to be kept at home or placed in separate classrooms, but now they are integrated into regular classrooms,” she added.

The study strongly demonstrated that “the meds in our schools are not given by school nurses. Seventy-five percent are given by others.”

Medications were administered most often by school secretaries, followed by health aides, teachers, parents and sometimes other students. Medication errors were 3.1 times more likely to occur when such unlicensed personnel dispensed the drugs, the authors estimated.

The results underscore a need to ensure “the people giving the meds who are not professionals are getting properly and consistently trained, supervised and evaluated,” said Judy Igoe, director of the Office of School Health at the University of Colorado Health Sciences Center in Denver and a 30-year veteran of the school nursing field.

The survey found that 80% of schools had training programs, but most were of two hours or less duration.

School nurses responding to the Iowa survey estimated that about 5.6% of youngsters in kindergarten through the 12th grade take medications on a typical school day, with 3.3% taking drugs for ADHD. Others take prescription medications for asthma, diabetes or seizures, and some take over-the-counter products such as pain relievers and cough medicines.

The nurses, who typically cover several schools, are in charge of ensuring that someone is available to give youngsters prescription pills, injections of insulin, puffs from an inhaler, or jabs from an Epi-pen to reverse allergic reactions.

Although the Iowa researchers didn’t track the outcomes of the errors reported by the nurses, the consequences of missing medications could range from convulsions among youngsters prescribed anti-seizure drugs to behavioral problems among those who take stimulants for ADHD.

“Because no one is tracking any of this in a systematic way over enough school districts, you really have difficulty . . . in identifying ways that would be effective to reduce these problems,” Igoe said.

One of the problems, she said, is a lack of uniformity in how the nation’s 15,000 public school districts handle health matters. Only about 20% have health advisory boards that set policy for school nurses. Without such bodies, “you haven’t got anything but one of those Charles Schulz cartoons of Lucy giving advice for 5 cents.”

In addition, some communities have implemented “zero tolerance” policies in which a child can not even carry an aspirin or Tylenol.

Such policies can conflict with the current movement in health care that encourages self-sufficiency, especially among older kids who can be taught to manage their own asthma or diabetes, Igoe said.

To cut down on errors, Igoe said, school employees giving the medications must know “there isn’t going to be a penalty for an error” and that no matter what, some errors are going to occur. Because without good reporting, “we can’t correct the system so it isn’t going to happen anymore.”

Help for school systems is coming in the form of voluntary guidelines for school health programs being established by the American Academy of Pediatrics and the National Assn. of School Nurses. Those are due for public review this spring.

The Iowa project was funded by pharmaceutical company Glaxo Wellcome and the Midwest Nursing Research Study.

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Recommended Guidelines for Schools

The practice of giving medication to students at schools varies among states and school districts. Although new national guidelines are expected next year, the Office of School Health at the University of Colorado Health Sciences Center in 1990 came up with the following minimum recommendations for all schools to follow:

* Medications should be dispensed to students only with parents’ written permission.

* Medications should be given only with written authorization from a physician or other health care provider licensed to prescribe. Long-term authorizations should be renewed each year.

* Written authorizations should include the name of the drug, the dosage, the mode of administration, the time interval between doses, the reason for its use and possible reactions.

* The permission and authorization forms should be part of the student’s health record. Medicine logs or charts should be on file in the nurse’s office.

* Students should receive counseling and instruction in self-care.

* Medication should be dispensed from an original and properly labeled container. Prescription medications should include the pharmacy name, student’s name, drug name, dosage, instructions for use, date prescribed and expiration date. Over-the-counter medications should be stored in containers with a manufacturer’s label identifying the medication and dosage schedules and bear the student’s name.

* The school employee who dispenses a drug should log the student’s name, medication, dosage, time and name of person giving the drug.

* Medication should be stored in a locked, clean container or cabinet. Medications requiring refrigeration should be kept in a secure area of the refrigerator.

* Any unused or expired medication should be picked up by parents and properly discarded in keeping with local health department policy. The medications should be destroyed only with parental permission.

Source: “National Guidelines for the Administration of Medications in Schools,” from the Office of School Health Programs, University of Colorado Health Sciences Center, January 1990.