“Denursifying” of schools puts children at added risk of medication errors
by Michael Cohen, Posted: February 7, 2012
According to the Philadelphia Federation of Teachers, the layoff of 47 school nurses in December has led to medications being handed out to school children by “principals, gym teachers, counselors, community liaisons, secretaries, and even aides who normally monitor the playground.” By doing this, the Federation contends, the school district is endangering the lives of the school children it is required to protect.
Hard to know what the precise situation is, but if I were the parent of a student in the school system, I’d be worried about the potential for medication mistakes.
Examples of medication errors in schools around the country are plentiful. A kindergartner was taken to the hospital on the first day of school after a teacher’s aide accidentally gave him another child’s medication. The 5-year-old boy became drowsy after he was given Catapres (clonidine), a blood pressure medication sometimes used to treat children who have attention deficit hyperactivity disorder (ADHD).
In another case, an eighth-grade student with ADHD was not responding to methylphenidate (Ritalin). He began to develop new symptoms and ended up in the emergency department, unconscious. The school nurse had been absent for a week, and medications were being administered by the school secretary, who, for three days had given the student anther student’s methadone (a powerful narcotic pain medication with significant side effects). The medication had been kept in an envelope listing only the handwritten generic name, not the student’s name. The methadone was mistaken as methylphenidate.
In a strikingly similar case, it was a school nurse who actually prevented a different child from suffering a methadone overdose when a prescription for methylphenidate was dispensed incorrectly by a pharmacist. I’m not sure a school secretary or teacher would have noticed the pharmacy dispensing error. Both medications start with m-e-t-h and are taken in similar doses. We have other cases in our error-reporting program database where school nurses have protected children from medication errors.
Then there’s also the story about a 9-year-old girl with asthma and allergies who collapsed and died in a Dayton, Ohio, elementary school. The school board there dismissed a third of its nursing staff two months before the incident due to budget cuts. The girl arrived at school feeling fine but started feeling dizzy. She collapsed on her way to an empty nurse’s office. The nurse who used to be there every day was being shared with other schools and was at another school that day. CPR was started by an occupational therapist, and paramedics were called to the school, but the child died a short time later after being taken to a hospital. The community questioned whether unavailability of the school nurse contributed to the child’s unnecessary death.
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Safe and correct medication administration during school hours has been a growing challenge. It is difficult to provide a normal environment for the students and at the same time implement the kinds of safeguards against medication errors that you would have in a medical setting. Many schools have insufficient staff and resources to handle the workload. Unlike hospital nurses, they don’t have computerized systems for storing medications or bar-coding systems to assure the proper drug is given to each student.
A common factor that contributes to medication errors in schools is the use of unlicensed assistive personnel (UAP) — principals, teachers, gym teachers, secretaries, and other UAP staff — to administer medications. Medication errors are three times more likely under these conditions. So training, skill, observation, and ongoing supervision of school medication administration by nurses is critical. But as school districts grapple with tight budgets, as they do here in Philadelphia, they’ve increasingly given UAP staff responsibility for medication administration. If I were a school nurse, I’d feel uncomfortable about delegating things like insulin injection, liquid medication by gastric-tube, and emergency epinephrine injection for allergic reactions to non-medical personnel. I’m sure UAP staff aren’t thrilled about it, either.
There’s a growing need for medication administration during the school day as the number of kids on medications for chronic conditions such as diabetes, asthma, and ADHD steadily increases. A study in the journal Pediatrics indicates that, along with the growing obesity problem in kids, the number of boys taking type 2 diabetes medication grew by 39 percent, and the number of girls climbed by 14.7 percent, in the three-year period from 2002 to 2005. The number of children with food allergies also continues to rise. Thus, school staff have become increasingly responsible for administering medications such as insulin or asthma inhalers, testing blood sugar, and keeping epinephrine injection and Benadryl handy for use during an allergy attack.
Of note, a University of Iowa survey of school nurses revealed that, during a typical day, 5.6 percent of children receive medication in school, with 3.3 percent receiving medications for ADHD alone. Medication errors were reported by 48.5 percent of the nurses. Most errors were associated with medications that should have been but were not given (79.7 percent). Problems also included giving medications to the wrong child, giving children the wrong medications, or giving medications at the wrong time or by the wrong route—an eye drop placed in the ear, for example. There are also errors associated with how medications are stored and drug diversion issues. The study showed that 75 percent of these medications were administered by UAP school staff. Even in states such as Iowa that require training and supervision of UAP, verification of skills is often nonexistent and supervision is often sporadic. Exactly how UAP training and supervision are being conducted in Philadelphia isn’t clear.
Here are some tips for parents:
As much as possible, parents should try to avoid sending medications to the school for staff to administer. If a medication must be given, work with the child's pediatrician to try to avoid doses that would be required during the school day. For example, some medications have a long acting form that could be given before or after school as an option.
If your child must take medication during the school day, ask what the school is doing to prevent medication mix-ups.
Provide a picture of your child with any medications that must be administered during school hours to help promote proper identification.
If providing the school with medication equipment like inhalers or pens used to administer insulin or epinephrine, don't assume school staff know how to use it. Take the time to write out instructions and go over them with school staff.
Also, older children should receive basic information about medicines and their proper use, and know to question anything that doesn't seem right.
Parents should make sure that any changes in medications or dose, including discontinuation of medications, are immediately communicated to the school staff.
This is a situation that needs to be watched closely. Nurses, teachers and others should report errors to us, in confidence, via our national medication error reporting program found here. We’ll keep track of these errors and compile them anonymously so they can be used for improvement.