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Release: Nov. 30, 2000

More children, more health concerns mean more school medication errors, UI study finds

IOWA CITY, Iowa -- Nearly half of the school nurses surveyed for a recent University of Iowa study reported medication errors in their schools in the past year. The most common error was a missed dose. Also, three quarters of the nurses reported that unlicensed personnel such as school secretaries, health aides and teachers dispense medications to students in their school systems.

The findings are contained in a study led by Ann Marie McCarthy, Ph.D., associate professor of nursing at the UI, and published in the November issue of the Journal of School Health. The survey, which was completed by 649 school nurses throughout the United States, looked at medication administration in schools, including policies and guidelines governing the dispensing of drugs to students, the types of medication commonly administered, and which school personnel were authorized to dispense medications.

Co-investigators of the study were Michael W. Kelly, Pharm. D., assistant professor (clinical) of pharmacy at the UI, and David Reed, Ph.D., assistant research scientist at the UI College of Nursing. The project was funded by Glaxo Wellcome, a pharmaceutical company, and the Midwest Nursing Research Society.

According to the study, school nurses estimated an average of 5.6 percent of students in grades kindergarten through 12 receive medications on a typical school day, with the majority -- 3.3 percent -- receiving medication for attention deficit hyperactivity disorder (ADHD). Other common medications include over-the-counter medications, analgesics, asthma and anti-seizure medications.

Of the school nurses who reported mistakes in administering medications to students in the past year, nearly 80 percent said the errors included missed doses. Other errors included giving an overdose or double dose (22.9 percent), giving medicines without authorization (20.6 percent), giving the wrong medicine (20 percent) or unspecified mistakes (29.8 percent).

McCarthy said few if any national studies have looked specifically at the administration of medications in schools. "The larger context is that there simply are more children in school with health conditions requiring medication now than in the past," McCarthy said. "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."

McCarthy also noted the rise in the number of children diagnosed as having ADHD and being medicated to control it. "That's a relatively recent phenomenon," she said.

"When you put it all together -- more children, more health problems and more medications -- there are more opportunities for errors to occur," McCarthy said.

The study used statistical methods to estimate the likelihood that various factors were related to medication errors in schools. Foremost among them was the use of so-called "unlicensed assistive personnel" such as school secretaries, health aides, teachers, parents and even other students to administer medications to students. Medication errors were 3.1 times more likely to occur with the use of unlicensed personnel to dispense medications to students, the study found. Just under
25 percent of the nurses surveyed said they administered all the medications in their schools.

In schools where unlicensed personnel dispense drugs to students, the individuals most commonly performing that function were secretaries (66.2 percent), health aides (39.7 percent), teachers (37.9 percent) and others (37.7 percent), the survey found. While three quarters of the schools had training programs for such individuals, the majority of programs were two hours or less in length. Most of the programs did, however, include information on such topics as oral, topical and inhalant medications and the use of emergency medications. Most of the in-service programs also were reviewed at least yearly, according to the study.

McCarthy believes nurses are uncomfortable about how medications are administered in their schools, particularly the use of unlicensed personnel to dispense drugs.

"The response rate to our survey, almost 65 percent, was well above what we expected, and many of the nurses included medication guidelines and written comments as well," McCarthy said. "That tells me they're quite concerned about this issue."

Despite its findings regarding medication errors, the study provides a great deal of encouragement to nurses, parents, teachers and others, McCarthy said.

"On the whole, we didn't find that children were being overmedicated," she said. "The rate at which students are receiving medication in school is consistent with the prevalence of health conditions requiring pharmacological management for those age groups."

McCarthy also noted that nearly all the nurses had written guidelines for administering medications in their schools. More than 93 percent of the school systems represented in the survey required written orders from a health provider in order to dispense prescription drugs, and even greater percentages required authorization from parents to dispense prescription drugs or nonprescription medications. Almost all the nurses reported they document the dispensing of drugs to students, including the student's name, the name of the medication, the dose, the time given and who administered the medication.

"There are a lot of good, solid practices going on," McCarthy said. "Errors are always a topic of concern, but it's important to remember they're a relatively small part of the picture."

The wide variance of standards -- both among states and within states -- for medication administration in schools points to the need for national guidelines, the study concludes.

"As we learn more about how medications actually are administered in schools throughout the country, we can begin to identify the best practices and use these to establish standards to improve health and safety for all students," McCarthy said.