B. Tablets and Capsules

Steps

1. Ensure school personnel have checked the 5 rights
2. Remove the bottle cap
3. Hold cap in one hand, bottle in the other
4. Pour the correct number of capsules or pills into the cap
5. Pour the correct capsules or pills from the cap to a clean medicine cup
6. Secure the cap back on the medication bottle
7. If medication is individually wrapped,remove wrapping while capsules or pill falls into the medicine cup
8. Provide the student with a glass of water
9. Give the student the medicine cup
10. Give the student the medicine cup
11. Observe the student swallowing the medication
12. Instruct the student to throw away or place into the cap the empty medication cup in the recycle (if applicable)
13. 13. Ensure the delegatee has demonstrated the 6th right: documentation
14. Places the medication bottle back securely in the locked area as directed

C. Sprinkles (Steps 1 to 8)
 

1. The school personnel check the 5 rights
2. Put gloves on hands
3. Separate and pour the capsule out on a small amount of food in a plastic medicine cup
4. Ensure school personnel checked the 5 rights again
5. Using a spoon, gently place the medication/food mixture in the student’s mouth to swallow or have the student use the spoon and do this step
6. Instruct the student to throw away or place the empty medication cup and spoon in the recycle bin (if applicable)
7. Ensure school personnel has demonstrated the 6th right: documentation
8. Place the medication bottle back securely in a locked cabinet as directed

D. Liquid Medication (Steps 1 to 13)
 

1. Gather supplies
2. The school personnel check the 5 rights
3. Place the plastic medication cup on a flat surface and keep your eye level with the cup
4. Pour the medication dose into the cup
5. If using a measured dropper, withdraw the correct amount
6. Wipe any drips from the bottle
7. Place the cap securely back on the medication bottle
8. Check the 5 rights again                                                 
9. Watch the student swallow the medication
10. Place the medication from the cup gently into the student’s mouth to swallow or have the student do this step.
11. Instruct the student to throw away or place the empty medication cup in the recycle bin (if applicable)
12. Ensure school personnel has demonstrated the 6th right: documentation
13. Place the medication bottle back securely in a locked cabinet or as directed by the prescription label

F. Eye Drops and Eye Ointments (Steps 1 to 16)

1. Gather supplies
2. The school personnel check the 5 rights
3. Position the student
4. Observe student’s eyes for change and report to school nurse
5. Put gloves on hands
6. Check the 5 rights again
7. Remove cap from eye medicine tube or bottle
8. Pull the student’s lower eyelid down gently with gloved hand and expose the conjunctival sac
9. Administer correct number of drops or ointment without the bottle or tube touching the eye, your fingers, or anything else
10. Have student gently close eyes
11. Place the cap securely back on ointment tube or bottle
12. Carefully blot away any excess liquid or ointment on student’s cheek
13. Instruct the student not to rub their eye(s)
14. Remove the gloves and place in the garbage
15. Ensure school personnel has demonstrated the 6th right: documentation
16. Place the medication back securely in a locked cabinet or as directed by prescription label

G. Topical Patches (Steps 1 to 14)

1. Gather supplies
2. The school personnel check the 5 rights
3. Gather supplies and put gloves on hands
4. Remove the old patch gently (if applicable)
5. Discard the old patch as directed
6. Gently clean the site where the old patch was located (if applicable)
7. Check the 5 rights again
8. Identify site for new patch application
9. Clean new site if directed (make sure not to apply patch over scarred areas)
10. Place initials, date and time on outside of new patch
11. Apply sticky side of patch to dry, clean skin and gently press to ensure adhesion
12. Remove gloves and place in garbage
13. Ensure school personnel has demonstrated the 6th right: documentation
14. Place the medication back securely in a locked cabinet or as directed by prescription label

H. Ear Drops (Steps 1 to 18)

1. Gather supplies
2. The school personnel check the 5 rights
3. Position student with the affected ear up
4. Observe the student’s ear for changes and report any to the nurse
5. Put gloves on hands
6. Check the 5 rights again
7. Remove the cap from the ear drop bottle
8. Student under 3 years old, gently pull the outer flap of the ear down and back to straighten the ear canal
9. Student 3 years of age and older, gently pull the outer flap of the ear upward and back to straighten the ear canal
10. Administer the correct number of drops per the prescription or manufacturer’s label
11. Rub the skin gently in front of the ear in a circular motion
12. Instruct the student to hold their position for a minute
13. Reposition and treat the other ear if directed
14. place the cap securely on the ear drop bottle
15. A cotton ball may be placed in the student’s outer ear to avoid leakage
16. Remove gloves
17. Ensure school personnel has demonstrated the 6th right: documentation
18. Place medication bottle back securely in a locked cabinet or as directed by the prescription label

I. Confidentiality, Universal Precautions, Documentation, and Reporting (Steps 1 to 6)

1. The delegatee (personnel) demonstrates understanding on how to document in the student's medication administration record
2. Personnel demonstrates understanding on how to document and report a medication error
3. Personnel demonstrates understanding on how to communicate with the school nurse regarding new or updated medications brought into the school by a parent or guardian
4. Personnel demonstrates understanding related to school policy and procedures on confidentiality, reporting and documenting
5. Personnel demonstrate understanding on how to address universal precaution
6. Personnel demonstrates understanding on how to count medications when they arrive at school, when they leave school or per district or school protocol

J. Inhalers With or Without A Spacer (Steps 1 to 14)

1. The school personnel checks the 5 rights
2. Shake the inhaler 10-15 times or for about 5 seconds
3. The school personnel checks the 5 rights again
4. Removes the cap and holds the canister in the upright position above the mouthpiece
5. Visually inspects the mouthpiece for any debris and checks the counter, if applicable
6. Has the student take a breath and exhale
7. Places the inhaler mouth piece gently in the student’s mouth on top of the tongue giving instructions to the student to seal lips around the mouth piece
8. If the student is using a spacer, have the student place the mouth piece of the inhaler into the back of the spacer and hold the inhaler and spacer between pointer finger and thumb with the student sealing the lips around the spacer’s mouth piece
9. Instruct the student to breathe slowly while administering dose and hold for 5-10 seconds before exhaling while using an inhaler
10. If the student is using a spacer, instruct the student to take several breathes before removing their mouth from the mouthpiece of the spacer to ensure the student inhales the medication
11. Place the cap back on the inhaler and if using a spacer, clean the spacer according to the manufacturer label
12. Encourage the student to rinse their mouth out after using their inhaler with water
13. Ensure the school personnel complete the 6th right: documentation
14. Return the medication to the student or place the medication back securely in a locked cabinet to as directed by the prescription label

K. Epinephrine Auto-Injectors (Steps 1 to 14)

1. Check the first 5 rights and follow the EAP, if applicable
2. Follow instructions for each individual brand of epinephrine auto-injector for this purpose the pen instructions are provided
3. Remove the auto-injector from the case, box, or tube packaging and hold in your fist
4. School personnel checks the 5 rights again
5. Pull the appropriately colored safety guard cap from the pen per the manufacturer instructions
6. Place the red or orange tip firmly against the side of the student’s thigh, about halfway between the knee or hip (on the outside of the clothing or directly on the skin)
7. The medication will auto-inject (Do not inject in a vein or the buttocks)
8. Hold the auto-injector in place for the prescribed time as indicated in the manufacturer’s instructions
9. Massage the area after injection
10. Place the used injector back in the safety case, box or tube packaging
11. Ensure the school personnel complete the 6th right: documentation
12. If the emergency medical services are notified, give them the used epinephrine auto-injector
13. Communicate with the school nurse
14. If emergency services are not notified, place the used epinephrine auto-injector in a sharps container

L. Awareness Training for Voluntary Stock Supply of Emergency Medications (Steps 1 to 11)

1. The school nurse delegates emergency medication administration.
2. The delegatee (school personnel) have completed the medication administration online course and have completed an annual skills demonstration with the school nurse listed in A-K of this document.
3. The school nurse has signed the medication administration certificate.
4. The delegatee has reviewed the school board approved stock medication school policy.
5. The delegatee has demonstrated competency on how to administer the emergency medication(s) using steps in the course and awareness video(s):
   1. Voluntary Stock Epinephrine Auto-Injector Awareness Video (2023)
   2. Voluntary Stock Bronchodilator Awareness Video (2023)
   3. Voluntary Stock Opioid Antagonist Awareness Video (2022)
6. The delegatee is able to identify signs and symptoms indicating when the voluntary emergency medications should be administered and knows to call 911.
7. The delegatee is able to demonstrate competency with the school nurse in the school’s protocol of communication and documentation.
8. The delegate and school nurse have signed the consent and delegation form.
9. The delegatee understands that they must report the administration of stock epinephrine use or stock bronchodilator use to the Department of Education within 48 hours of administration using the reporting format below:
   1. Stock Epinephrine Auto-Injector Reporting Form
   2. Stock Bronchodilator or Bronchodilator Canister Use Reporting Form
10. The delegatee demonstrates competency in how to dispose of used emergency medication.
11. Documentation of delegation is completed by the school nurse.

Additional Medication and Health Service Modules

The school nurse may have the delegatee complete additional specialized modules after the school personnel has completed the required medication administration course. These modules may not be taken unless the school personnel have completed all of the requirements to be certified in the regular medication administration course. The checklists are listed below for each additional module (M-W). The school nurse is responsible for evaluation of delegation. The instructional steps assist the registered nurse working under the auspices of the school or program in professional judgement and accountability of delegation. Additional steps may be required depending on the learner, school or program needs.

M. Rectal Diazepam (Steps 1 to 24)

1. Follow the EAP. Stay calm. Have someone notify the indicated personnel, obtain the medication, begin timing the seizure, wash your hands and check the 5 rights
2. Position of student in the recovery position on a flat, safe surface on their side
3. Provide privacy (if possible)
4. Gather supplies
5. Put on gloves
6. Get the syringe and note that the seal pin is attached to the cap or green ready band is visible
7. Check to ensure the correct dose is dialed and the time for when to administer the medication is met
8. Check the 5 rights again
9. Push with the thumb and pull to remove the cap from the syringe (Be sure the seal pin is removed from the cap)
10. Lubricate the rectal tip with lubricating jelly
11. Position yourself with the student facing you
12. Expose the buttocks and move the student’s upper leg forward to expose the rectum. Provide privacy (if applicable)
13. Separate the buttocks
14. Gently insert the syringe tip into the rectum with the rim snug against the rectal opening
15. Slowly count to three while gently pushing the plunger into the syringe until it stops
16. Slowly count to three before removing the syringe from the rectum
17. Slowly count to three while holding the buttocks together to prevent leakage
18. Pull the student clothing back to cover the buttocks
19. Keep the person on their side facing you and stay with the student
20. Note the time when the medication was administered and continue to observe the student
21. Follow the remaining steps as outlined by the student’s EAP and notify the school nurse, parents or Emergency Medical Services (EMS) Provide EMS with the used medication if indicated or dispose of the medication per the manufacturer’s label
22. Remove gloves and wash hands
23. Communicate with the school nurse
24. Ensure school personnel complete the 6th right: documentation

N. Intranasal Seizure Medication with an Atomizer (Steps 1 to 23)

1. Stay calm and follow the EAP (Have someone notify the indicated personnel, obtain the medication, begin timing the seizure, wash your hands and check the 5 rights, check to ensure the medication is not expired)
2. Position of student on a flat, safe surface on their side
3. Gather supplies and put on gloves
4. Mark the syringe at the level that the medication needs to be drawn up and draw up the correct amount of medication to account for the medication that will remain in the neck of the nasal atomizer as outlined by the healthcare provider or pharmacist
5. Fill the syringe with air to the marked line by pulling the plunger back until the top of the plunger reaches the mark
6. Check the 5 rights again
7. Remove the protective plastic cap off the vial and wipe the top of the vial with an alcohol swab
8. Connect the needle to the marked syringe and twist to secure it on to secure
9. Remove the needle cap and stick the needle through the rubber stopper of the medication vial
10. With the needle remaining in the vial, flip the bottle upside down
11. While holding down the plunger with the vial turned up, visualize to make sure the needs tip is in the medication (If it is not, adjust the needle in the vial to ensure it is fully in the liquid medication)
12. Pull back on the plunger and allow the syringe to fill with the medication to the marked level
13. If there are no air bubbles and you have the correct amount in the syringe, remove the needle from the vial
14. Replace the needle cap by scooping the cap with the needle from a flat clean surface (Never recap a needle by holding onto the needle cap)
15. Gently twist the needle off of the syringe and dispose of the needle in a red sharps container
16. Attach the nasal atomizer to the syringe and view the student’s nostril for obstruction
17. Gently place one hand on the student’s forehead and place the tip of the atomizer in the student’s nostril snuggly facing up and outwards (or as indicated by the child’s healthcare provider)
18. Inject the medication using the atomizer to administer the medication as a mist in the student’s nostril(s) per the healthcare provider’s instruction or as stated in the EAP
19. Note the time that the medication was administered and continue to observe the student
20. Follow the remaining steps as outlined by the student’s EAP and notify the school nurse, parents or Emergency Medical Services (EMS) (Provide EMS with the used medication if indicated or dispose of the medication per the manufacturer’s label)
21. Remove your gloves and wash your hands
22. Communicate with the school nurse
23. Ensure school personnel complete the 6th right: documentation

O. Buccal Seizure Medication (Steps 1 to 20)

1. Follow the EAP
2. Stay calm (Have someone notify the indicated personnel, obtain the medication, begin timing the seizure, wash your hands and check the 5 rights, check to ensure the medication is not expired)
3. Gather supplies, put on gloves and ensure the child is in the recovery position
4. Mark the syringe at the level that the medication needs to be drawn up (Draw up the correct amount of medication as outlined by the healthcare provider or pharmacist)
5. Fill the syringe with air to the marked line by pulling the plunger back until the top of the plunger reaches the mark
6. Check the 5 rights again
7. Remove the protective plastic cap off the vial and wipe the top of the vial with an alcohol swab
8. Connect the needle to the marked syringe and twist to secure it on to secure
9. Remove the needle cap and stick the needle through the rubber stopper of the medication vial if the vial requires the use of a needle
10. With the needle and syringe remaining in the vial, flip the bottle upside down
11. While holding down the plunger with the vial turned up, visualize to make sure the needle or syringe tip is in the medication. If it is not, adjust the needle or syringe tip in the vial to ensure it is fully in the liquid medication
12. Pull back on the plunger and allow the syringe to fill with the medication to the marked level
13. If there are no air bubbles and you have the correct amount in the syringe, remove the needle from the vial
14. If the medication requires a needle, replace the needle cap by scooping the cap with the needle from a flat clean (Never recap a needle by holding onto the needle cap)
15. Gently twist the needle off of the syringe and dispose of the needle in a red sharps container
16. Open the child’s lips gently and slowly insert the medication from the syringe into the inside of the child’s lower cheek along the gum line (There is no need to open the child’s jaw and the solution does not need to be swallowed)
17. Note the time that the medication was administered and continue to observe the student
18. Follow the remaining steps as outlined by the student’s EAP and notify the school nurse, parents or Emergency Medical Services (EMS). Provide EMS with the used medication if indicated or dispose of the medication per the manufacturer’s label
19. Remove your gloves and wash your hands
20. Communicate with the school nurse and ensure school personnel complete the 6th right: documentation

P. Insulin Administration by Injection (Steps 1 to 20)

1. Wash hands and check 5 rights
2. Gather supplies and medication outlined in the medication administration record(MAR)
3. Put on gloves
4. Check insulin for discoloration, lumps or crystals (demonstrate understanding that if this is observed, to stop and communicate with the nurse. If cloudy,roll in between your hands 20 times
5. Review on the MAR where the last injection was given and choose an alternate site with the student. Check the rights again.
6. Wipe the top of the vial with an alcohol pad.
7. Gently remove the cap off of the insulin syringe
8. Pull the plunger out slowly to the number of units to be administered
9. Push the needle into the vial that is sitting on a flat surface and plunge the air into the space in the bottle.
10. Keeping the needle in the bottle, turn the bottle upside down, ensure the tip of the needle is in the insulin in the bottle and withdraw slowly the units of insulin needed and provided by the healthcare provider or within parameters the healthcare provider has given parents to adjust
11. Tap syringe gently to remove any air bubble
12. Check the number of units to be administered from the MAR for a third time and check what is drawn up in the syringe
13. Clean the injection site with an alcohol wipe and wait for it to dry
14. Pinch up skin gently with free hand and insert the needle at a 90-degree angle
15. Release pinch and push plunger in slowly
16. Pull the needle straight out
17. Wipe any bleeding away (if any) with an alcohol wipe
18. Delegatee states they understand to never recap the needle
19. Remove gloves and watch hands
20. Ensure school personnel complete the 6th right: documentation

Q. Insulin Pen Injection Skills (Steps 1 to 24)

1. Wash hands and check 5 rights
2. Gather supplies needed, including the medication as outlined in the student’s medication administration record (MAR)
3. Review where the last injection was given and choose an alternate site with the student (if applicable)
4. Check the 5 rights again and put on gloves
5. Pull the pen cap slowly and remove the cap from the pen
6. Visually inspect and for cloudy insulin, roll the pen back and forth until evenly mixed
7. Wipe pen end rubber seal with an alcohol pad
8. Screw new capped needle straight onto the pen tip until tight (sizes of the needle will vary depending on what the healthcare provider indicates is best for the student)
9. Hold the pen pointing up and remove the outer shield (keep to use for needle removal). Remove the inner shield
10. Prime the pen per the manufacturer’s instruction
11. Dial the desired dose of insulin
12. Check the number of units dialed on the pen a third time against the MAR
13. Choose a new injection site with the student (if applicable)
14. Pinch the skin with the free hand and hold the pen against the site held with the other hand at a 90-degree angle and press the injection button, wait 5-10 seconds per instruction
15. Release pinch and release the injection button
16. Remove the needle straight out and wipe any blood away with an alcohol wipe (if any)
17. Check the pen and make sure that the full dose was administered
18. Carefully replace the outer needle shield
19. Remove the capped needle turning counterclockwise
20. Discard used needle (and pen if disposable) in the sharp’s container
21. Replace the pen cap
22. Remove the gloves and wash hands
23. Ensure school personnel complete the 6th right: documentation
24. Store as instructed per the manufacturer’s instruction

R. Insulin Pump Skills (Steps 1 to 14)

1. Washes their hands and checks the five rights
2. Gathers supplies and the medication administration record and/or other documentation records required to provide delegated care
3. The school nurse reviews the student’s individual device with the school personnel and provides training on the device
4. The school personnel demonstrates competency in the review of the settings used on the student’s device as determined by the school nurse’s decision to delegate specific tasks and the student’s needs
5. The school nurse reviews the EAP with the school personnel
6. Completes an insulin to carb counting ratio training and demonstrate competency with the school nurse (carb counting training is available in the module)
7. Completes training and demonstrates competency with the school nurse on how to check the student’s blood sugar using the device provided by the parent and how to address highs and lows (e.g. blood glucose monitors or continuous glucose monitor)
8. Completes training and demonstrates competency on how to utilize the specific settings permitted through delegation on the student’s pump device in accordance with manufacturer instructions
9. Completes training and demonstrates competency with checking the 5 rights again before making any insulin adjustment to scheduled or episodic blood sugar checks following the steps in either the Medication Administration Records (MAR) or school documentation forms as provided to you by the school nurse
10. Is able to successfully explain and demonstrate specific settings and uses of the pump to the school nurse and what the student’s pump is preprogrammed for per the child’s healthcare provider orders
11. Demonstrates competency with the school nurse on how to troubleshoot the pump per the manufacturer, how to change the infusion tubing if required or the site as directed
12. Demonstrates competency to the school nurse in understanding the importance of checking the 5 rights prior to administering medication or performing a delegated nursing task, or making any adjustment
13. Demonstrates competency on the protocol for communication with the school nurse
14. Ensure the delegatee has demonstrated competency with the school nurse on the 6th right of delegation with all delegated care: documentation

S. Intranasal Medication (Steps 1 to 12)

1. Follow the EAP
2. Stay calm (Have someone notify the indicated personnel, obtain the medication, begin timing the seizure, wash your hands and check the 5 rights, check to ensure the medication is not expired)
3. Gather supplies and put on gloves
4. Check the 5 rights again
5. Hold the nasal spray with one finger on each side of the nozzle (Do not prime the pump or push it in until it is ready to be used)
6. View the student’s nostril for obstruction
7. Place the nozzle in one nostril or side of the nose and push the plunger in to give the medicine then remove the nasal spray device
8. Note the time that the medication was administered and continue to observe the student
9. Follow the remaining steps as outlined by the student’s EAP and notify the school nurse, parents or Emergency Medical Services (EMS)
10. Provide EMS with the used medication if indicated or dispose of the medication per the manufacturer’s label
11. Remove your gloves and wash your hand
12. Communicate with the school nurse

T. Glucagon Injection Kit (Steps 1 to 21)

1. Wash your hands, put on gloves and check the 5 rights
2. Gather the needed supplies; including the medication and follow the steps in theEAP
3. Check the 5 rights again and put ongloves
4. 4. Position the student in the recovery position on their side
5. Follow the glucagon kit instructions for the individual student
6. Flip the cap from the bottle of inactive glucagon powder and wipe the rubberstopper with an alcohol pad
7. Carefully remove the needle protector from the syringe
8. Inject the entire contents of the syringe into the bottle of glucagon powder
9. Flip the bottle up with on hand on the bottle and the other on the syringe, held together
10. Gently swirl the liquid until the powder dissolves and is clear (do not use unless the solution is clear and water-like consistency)
11. Pull back gently on the plunger and withdraw the prescribed dose in the syringe per the MAR
12. Wipe the injection site with an alcohol pad(buttocks, upper arms, or thigh)
13. Insert the needle into the loose tissue the cleansed injection site and inject the glucagon solution as prescribed
14. Withdraw the needle and apply light pressure at the injection site with a gauzepad
15. Retract the needle guard (if applicable)and place the needle in a red sharp’scontainer
16. Keep the student in the recovery position and stay with the student
17. Feed the student as soon as he or she is awake and is able to swallow by giving a quick sugar and long acting sugar source or as directed by the student’s emergency action plan
18. Follow the instructions in the EAP if the student is not conscious (there might be a requirement for a second dose)
19. Remove gloves and wash your hands
20. Communicate with the school nurse
21. Ensure the delegatee has demonstrated competency with the school nurse on the 6th right of delegation with all delegated care: documentation

U. Glucagon Auto-Injector Skills (Steps 1 to 14)

1. Wash your hands, put on gloves and check the 5 rights
2. Gather the needed supplies and follow theEAP
3. Have the student lay on their side if conscious (If the student is unconscious,roll the student to the recovery position on their side)
4. Check the 5 rights again
5. Expose the injection site: upper left or right arm, stomach, right or left thigh
6. Pull the red cap off of the emergency medication pen
7. Push the yellow end down onto the skin firmly and hold for 5 seconds (The window of the pen will turn red when all the medication is administered)
8. Keep the student on their side in the recovery position
9. Dispose of the pen in a red sharp container (unless otherwise indicated in the student’s EAP)
10. Remove your gloves and wash your hands
11. Stay with the student
12. Follow the EAP steps in addition to safe emergency medication administration
13. Communicate with the school nurse
14. Ensure the delegatee has demonstrated competency with the school nurse on the 6th right of delegation with all delegated care: documentation.

V. Nebulizer Skills (Steps 1 to 17)

1. Wash your hands and check the 5 rights 

2. Gather the needed supplies, including the medication and follow the steps in the EAP (if applicable) 

3. Follow the instructions for medication administration and use of the nebulizer and supplies 

4. Have the student sit comfortably next to the nebulizer compressor (you can explain the procedure if not an emergency and provide a quiet activity to pass the time) 

5. Ensure the delegatee places the nebulizer on a clean level surface, hose is connected to the compressor and the machine is plugged into the outlet

6. Review the 5 rights again 

7. Put on gloves and prepare the medication by pouring it into the nebulizer medication cup 

8. Attach the hose and T-mouthpiece or mask to the medicine cup, ensuring the cup keeps upright to prevent spills 

9. Turn the nebulizer machine power switch on and check for a mist from the mouthpiece or mask 

10. Place the mask gently over the students nose and mouth or hand the student the mouthpiece to have them place it in their mouth 

11. Have the student inhale through the mouthpiece or mask until the medication is completely gone. (gently tap the cup as needed, this may take up to 10 to 15 minutes) 

12. Encourage the student to rinse their mouth with water after using the nebulizer

13. Follow any additional steps in the student’s emergency action plan (if applicable) 

14. Disconnect the mouthpiece or mask from the tubing and unscrew the medication top, clean according to the manufacturer’s recommendations 

15. Remove your gloves, wash hands and place the nebulizer and supplies away as directed and secure medications back into secure location 

16. If this is part of the emergency action plan, communicate with the school nurse 

17. Ensure the delegatee has demonstrated competency with the school nurse on the 6th right of delegation with all delegated care: documentation

W. Gastrostomy Tube (GT) Medication and Feeding (Steps 1 to 21)

1. Wash your hands and check the 5 rights 

2. Gather the needed supplies, including the medication and steps as outlined in the Medication Administration Record (MAR) 

3. Put on gloves and prepare feeding or medications as ordered (ensure whether a medication is able to be crushed or dissolved per the prescription label) 

4. Remove the plunger from a large syringe and set to the side 

5. Place each medication separately in the prescribed amount of water in individual plastic medication cups 

6. Ensure the student is in an upright position either sitting or with the head above 30 degrees 

7. Remove the plug to cap on the tube that you have been instructed to use 

8. With the plunger removed from the syringe, connect the large syringe to the GT holding it in an upright fashion with the opening at the top to allow air bubbles to escape from the tube 

9. Provide an initial flush with the prescribed amount of water by pouring it slowly to be fed by gravity through the tube and into the stomach before administering any feeding or medication 

10. Administer each medication one at a time with the prescribed amount of water flush provided between each medication or administer the feeding as delegated by your school nurse 

11. After the medications are administered or the feeding, flush the GT with the prescribed amount of water using gravity and keep the student in an upright position either sitting or with their head above 30 degrees 

12. Replace the plug or cap on the GT 

13. Check the area around the GT for signs of skin irritation or redness 

14. Clean the supplies as directed 15. Dispose of any empty plastic medication cups or empty feeding supplies in the recycle bin 

15. Remove your gloves 

16. Wash your hands 

17. Communicate with the nurse if there are any unusual issues 

18. Store the medications securely in a locked cabinet or as directed on the prescription label 

19. Store the supplies in the designated area as directed by the school nurse 

20. Ensure the delegatee has demonstrated competency with the school nurse on the 6th right of delegation with all delegated care: documentation

X. Intravenous Medication Administration By The School Nurse:

Administration of intravenous medications using aseptic technique is within the scope of practice of the registered school nurse in accordance with the IAC 655.6.. This administration route is a similar nursing service provided in the homecare setting and would follow treatment orders from the child’s healthcare provider.

Children with chronic health conditions may attend school who require this service by the licensed school nurse.

The decision to administer lies solely with the licensed registered school nurse who would be required to feel comfortable performing the nursing task, have adequate experience, supplies, ability to verify medication orders and maintain standards of practice, to include but not limited to: hand hygiene, student assessment, inspect the intravenous site, clean the injection port, connect the syringe, administer flush(s) as outlined in the treatment plan, administer the medication, maintain close observation within their practice, report any complications, proper disposal of used materials, and complete documentation in addition to other specified requirements from the healthcare provider orders given to the school nurse by the parent. 

During the delivery of this nursing care, the school nurse would not be available for interruption with other student’s health needs. 

Y. Other Healthcare Devices:

Every child in Iowa has different healthcare providers, unique healthcare needs, and may have different healthcare devices. School nurses will be brought various devices from parents for the care of their child(ren). The school nurse collaborates with parents/guardians and relies on the manufacturers of the device and the child(ren)’s licensed healthcare provider(s) for information to ensure safe delivery of care. Parents may not understand that the specialized practice of school nursing is unlike a static healthcare facility (e.g. hospital or clinic) who may use certain brand(s) of devices that extends beyond parent choice. This care is also different from the care parents would provide in the home setting. The school nurse employed by the business (school) is held to higher regulatory standards than parents at home and is serving hundreds of children.

Z. Other Topics: Medication Receipt, Storage, Waste, and Minimization: 

The school nurse will instruct the paraprofessional on the procedures and protocols related to medication receipt, storage, waste and minimization.

Medications counting and arriving to school considerations:

• Inform parents that the first dose of a newly prescribed medication should not be administered at school if at all possible
• The school nurse should explain the medication to the student prior to the first time it is administered at school.
• Medication should be delivered to school by a responsible adult in an original pharmacy labeled container or manufacturer’s package.
• Access to nonemergency medication is restricted to the school nurse and staff trained to administer medications unless parents have provided written consent for self-administration per policy
• Medication is counted and documented upon receipt and signed by the school staff member and the adult delivering the medication or two school staff members
• The school only keeps the medication needed for the student and the remainder is sent home with the responsible adult.
• The school nurse is notified by school personnel whenever a new medication is brought to the school.
• Controlled medication is counted upon receipt and with each dose by the school personnel and responsible adult or two school personnel and this count is documented with the signature and initials of the 2 counters
• Counts by two school personnel should be conducted and documented  with the count, signatures, and initials of the two counters no less than weekly.

Medication storage considerations:

• All nonemergency medication should be stored securely in locked storage.
• Medications requiring refrigeration should be stored in locked refrigerators per the temperature specifications of the manufacturer, and the refrigerator temperature should be monitored on a regular basis.
• Medication should not be stored with food.
• Emergency medications should be stored securely with a plan for quick access to the student or learner’s location.
• Controlled substances should be double-locked.
• Medication should not be left unattended or in an unsecured room.

Medication minimization, return, and waste considerations:

• School should practice minimization and only maintain what is needed
• Any leftover medications should be returned to the parents at the end of the school year, upon transfer to another school, or if medication is discontinued or expired.
• Medication return should be documented, dated, timed, and signed by the school personnel and the parent.
• Medications not retrieved by parents should be disposed of according to packaging instructions and state health and environmental protection requirements.
• Document in the student’s record that medication was disposed of.
• Consider police and school resource officers to pick up leftover medication for the two national “Take back” days for disposal and to decrease drug diversion risks.
• Schools generating hazardous waste from the left over voluntary stock medications or medications that parents do not pick up must maintain fiscal responsibility and comply with the disposal through the Resource Conservation and Recovery Act (RCRA).
• Iowa School Hazardous Waste and Medication Management Guidance (2022)

Supplements

At times, school nurses are asked by parent(s) and guardian(s) to administer supplements or other products purchased online that are not FDA approved with the request for the administration to be at a nonstandard, preferential time during the school day or during school activity. School nurses approach families in an ethical manner without judgement regarding the patient’s choice of treatment (National Council of State Boards of Nursing, 2019). School nurses must also maintain accountability and utilize their professional nursing judgment in their practice to determine whether an over the counter or prescribed drug is safe to administer. A necessary component of knowledge in nursing care includes the availability of moderate to high quality evidence-based research and comprehensive understanding of nursing standards, state and federal laws. School nurse must additionally comply with school policies. 

The FDA offers formal, evidence-based evaluation of medications to assist licensed healthcare providers with information on safe dosage, storage, standardized dosing times, possible drug interactions, possible side effects, or toxic effects of a drug to protect the individual who is taking the medication. School nurses follow school district policies regarding medication administration, delegation of medication administration, and maintain accountability for their licensed nursing practice related to the safe provision of clinically competent, evidence-based health services for students in their school or district

Medication on Field Trips

Field trips require approval from school administrators. Schools have processes over a course of time for educators to make a request for a field trip prior to approval.. 

Best-practice for schools is for school nurses to be notified at the first time of request for field trips to ensure there is properly trained, qualified school personnel to administer medications in accordance with school policy. A qualified designated person accompanies children who need medications on field trips, replicating the procedures used in the school building using the training and skills check to ensure competency as defined in IAC 281.14.1. Licensed educators and school nurses maintain accountability for their practice. The licensed school nurse retains accountability in the safe delegation of medication administration and training prior to a nursing task or activity being performed (IAC 655 Chapter 6). 

Licensed educators do not aid, assist or abet an unlicensed individual in completion of acts for which licensure is required (IAC 282 Chapter 25). Together, licensed education practitioners and licensed school nurses follow regulatory standards and guidance in the delegation of their professional practices to protect the health and safety of Iowa students.

Medication Errors (Steps 1 thru 13)

A medication error is defined by the Food and Drug Administration as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. (National Coordinating Council for Medication Error Reporting and Prevention, 2019).

 A few samples of medication errors that can occur in schools include: 

• failure to administer medication to the student
• failure to administer medication within the designated time
• failure to administer the correct dosage of medication
• failure to administer medication by proper route
• failure to administer medication according to generally accepted standards of practice
• administering the wrong medication to the wrong student
• administering medication without parent authorization, or
• administering a prescription medication to a student who does not have a prescription.

Medication errors can occur as human care may be fallible. School personnel should notify the school nurse, parent, healthcare provider and administration if a medication error occurs right away to create a safe environment. Staying connected, transparent and communicating with parents is an essential reparative step in addressing improving the process of medication administration. It is best-practice for school nurses and school personnel to have a dialogue with parents that includes: 

• Recognition of the adverse outcome
• Regret by offering empathy
• Responsibility where needed and explain how the event happened
• Remedy by explaining next steps to correct and prevent reoccurrence
• Remain engaged by communicating with parents

When a medication administration error occurs by a paraprofessional:

1. Keep the student in the health room (or room where medication was administered)
2. If the student has already returned to class, have someone accompany the student back to the room where medication was administered
3. Observe the student’s status and document what you observe
4. Remain calm and do not alarm the student
5. Identify the incorrect dose or type of medication taken by the student
6. Notify the school nurse, parents and administrator immediately
7. Notify the prescribing provider of the medication
8. Notify the parents and prescribing provider of the other child’s medication (if applicable to the error)
9. If contacting the Poison Control Center for instructions:
   1. give the name and dose of the medication taken in error
   2. give the student’s age and approximate weight, if possible
   3. give the name and dose of any other medication the student receives, if possible
   4. Follow instructions from the Poison Control Center, if possible.
      1. If unable to follow their instructions, explain the problem to the Poison Control Center to determine if the student should be transported for emergency care
10. Complete a Medication Administration Incident Report form.
    1. Carefully record all circumstances, the student’s status, communications and actions taken, including instructions from the Poison Control Center or the student’s health care provider..
    2. All reports are to be filed and kept according to school or program policy
11. Give or send the completed Medication Administration Incident Report form securely to the delegating school nurse within 24 hours of the incident.
12. Follow any additional school or program procedure
13. Debrief with the school nurse.

School Nurse Responsibilities:

• Upon notification of medication error, contact the parents of the student and health care provider, if not already completed
• Review Medication Administration Incident Report form immediately with the delegatee who was involved in medication error
• Provide additional education to employee(s) who was involved in medication error
• Ensure competency of employee who was involved in medication error on safe medication administration
• If necessary, revoke delegation and identify someone else to assume responsibility of medication administration
• In conjunction with school administration, review data on Medication Administration error report forms at least quarterly to understand:
  • the factors that contribute to errors and
  • identify if the errors are related to systems and/or process issues
  • Identify process changes that may need to occur to improve medication administration procedures, for example:
    • Reducing distractions when/where the medications are being given
    • Having photos of the student attached to the medication administration form to assist with proper identification
    • Providing more frequent medication administration education refreshers

Medication Administration Services Continuous Quality Improvement Practice

Continuous quality improvement (CQI) practice is a nursing leadership initiative that the school nurse uses to eliminate or reduce medication errors, increase medication minimization, reduce medication waste, increase efficiency, and strengthen internal (nurses, school personnel) and external (families/students) satisfaction. 

It is an ongoing process that evaluates how the process of medication administration works (from the time the student first enrolls in school to the time the student requires medication administered at school) and ways to improve its processes. Medication errors can occur anywhere along the route: from the healthcare provider who prescribes the medication, the pharmacist who fills the script, the parent who completes the medication consent form, to the school nurse or delegatee who administers the medication. 

1. Schools should use standardized, comprehensive, detailed forms for:
   1. parent consent for medication administration,
   2. medication administration documentation,
   3. medication error reporting including identification of contributing factors and risk-reductions strategies /corrective action,
   4. standing orders for voluntary stock emergency supply (if applicable),
   5. self-administration consent forms
2. A systematic review of medication administration should be conducted at least annually.
3. Review alignment between state laws and district policy annually for updates (Note: CPGs may be more rigorous than state laws that are not based on evidence).
4. Conduct an audit of the medication administration process annually:
   1. An audit should include:
      1. all documentation:
         1. consent form
         2. medication administration records.
5. Procedure for field trips/off-campus medication administration with school nurse notification
6. Create a culture of safety
   1. Increase culture of safety by decreasing stigma and increasing vigilance for medication errors.
   2. Create a nonpunitive, fair and just culture and reporting system through training and forums on culture and continuous quality improvement.
   3. Provide Second Victim support for the licensed provider or UAP who experiences a medication error.
   4. School district policy should include medication error reporting protocol;
      1. standard forms are recommended.
      2. “Sentinel events” where significant patient harm occurs” reported to school leadership.
      3. Consider community partnerships with local pharmacists and community healthcare providers in the quality improvement