Caring for Our Childen (CFOC)

Chapter 9: Administration

9.2 Policies

9.2.3 Health Policies

9.2.3.9: Written Policy on Use of Medications


The facility should have a written policy for the administration of any prescription or non-prescription (over-the-counter [OTC]) medication. The policy should address at least the following:

  1. The use of written parental/guardian consent forms for each prescription and OTC medication to be administered at the child care facility. The consent form should include:
    1. The child’s name;
    2. The name of the medication;
    3. The date(s) and times the medication is to be given;
    4. The dose or amount of medication to be given;
    5. How the medication is to be administered;
    6. The period of time the consent form is valid, which may not exceed the length of time the medication is prescribed for, the expiration date of the medication or one year, whichever is less.
  2. The use of the prescribing health professional’s authorization forms for each prescription and OTC medication to be administered at the child care facility.
  3. The circumstances under which the facility will agree to administer medication. This may include the administration of:
    1. Topical medications such as non-medicated diaper creams, insect repellants, and sun screens;
    2. OTC medicines for fever including acetaminophen and ibuprofen;
    3. Long-term medications that are administered daily for children with chronic health conditions that are managed with medications;
    4. Controlled substances, such as psychotropic medications;
    5. Emergency medications for children with health conditions that may become life-threatening such as asthma, diabetes, and severe allergies;
    6. One-time medications to prevent conditions such as febrile seizures.
  4. The circumstances under which the facility will not administer medication. This should include:
    1. No authorization from parent/guardian and/or prescribing health professional;
    2. Prohibition of administering OTC cough and cold medication;
    3. Not administering a new medication for the first time to a child while he or she is in child care;
    4. If the instructions are unclear or the supplies needed to measure doses or administer the medication are not available or not in good working condition;
    5. The medication has expired;
    6. If a staff person or his/her backup who has been trained to give that particular medication is not present (in the case of training for medications that require specific skills to administer properly, such as inhalers, injections, or feeding tubes/ports).
  5. The process of accepting medication from parents/guardians. This should include:
    1. Verifying the consent form;
    2. Verifying the medication matches what is on the consent form;
    3. Accepting authorization for prescription medications from the child’s prescribing health professional only if the medications are in their original container and have the child’s name, the name of the medication, the dose and directions for giving the medication, the expiration date of the medication, and a list of warnings and possible side effects;
    4. Accepting authorization for OTC medications from the child’s prescribing health professional only if the authorization indicates the purpose of the medication and time intervals of administration, and if the medications are in their original container and include the child’s name, the name of the medication, dose and directions for use, an expiration date for the medication, and a list of warnings and possible side effects;
    5. Verifying that a valid Care Plan accompanies all long-term medications (i.e., medications that are to be given routinely or available routinely for chronic conditions such as asthma, allergies, and seizures);
    6. Verifying any special storage requirements and any precautions to take while the child is on the prescription or OTC medication.
  6. The proper handling and storage of medications, including:
    1. Emergency medications – totally inaccessible to children but readily available to supervising caregivers/teachers trained to give them;
    2. Medications that require refrigeration;
    3. Controlled substances;
    4. Expired medications;
    5. A policy to insure confidentiality;
    6. Storing and preparing distribution in a quiet area completely out of access to children;
    7. Keeping all medication at all times totally inaccessible to children (e.g., locked storage);
    8. Whether to require even short-term medications be kept at the facility overnight.
  7. The procedures to follow when administering medications. These should include:
    1. Assigning administration only to an adequately trained, designated staff;
    2. Checking the written consent form;
    3. Adhering to the “six rights” of safe medication administration (child, medication, time/date, dose, route, and documentation) (1);
    4. Documenting and reporting any medication errors;
    5. Documenting and reporting and adverse effects of the medication;
    6. Documenting and reporting whether the child vomited or spit up the medication.
  8. The procedures to follow when returning medication to the family, including:
    1. An accurate account of controlled substances being administered and the amount being returned to the family;
    2. When disposing of unused medication, the remainder of a medication, including controlled substances.
  9. The disposal of medications that cannot be returned to the parent/guardian.

A medication administration record should be maintained on an ongoing basis by designated staff and should include the following:

  1. Specific, signed parental/guardian consent for the caregiver/teacher to administer medication including documentation of receiving controlled substances and verification of the amount received;
  2. Specific, signed authorization from the child’s prescribing health professional, prescribing the medication, including medical need, medication, dosage, and length of time to give medication.
  3. Information about the medication including warnings and possible side effects;
  4. Written documentation of administration of medication and any side effects;
  5. Medication errors log.

The facility should consult with the State Board of Nursing, other interested organizations and their child care health consultant about required training and documentation for medication administration. Based on the information, the facility should develop and implement a plan regarding medication administration training (9).

RATIONALE
Administering medication requires skill, knowledge and careful attention to detail. Parents/guardians and prescribing health professionals must give a caregiver/teacher written authorization to administer medication to the child (12). Caregivers/teachers must be diligent in their adherence to the medication administration policy and procedures to prevent any inadvertent medication errors, which may be harmful to the child (11). There is always a risk that a child may have a negative reaction to a medication, and children should be monitored for serious side effects that may require an emergency response. Because children twenty-four months of age and younger are in a period of rapid development and are more vulnerable to the possible side effects of medications, extra care should be given to the circumstances under which medications will be administered to this population. A child may have a negative reaction to a medication that was given at home or to one administered while attending child care. For these reasons caregivers/teachers need to be aware of each of the medications a child received at child care as well as at home. They should know the names of the medication(s), when each was given, who prescribed them, and what the known reactions or side effects may be in the event that a child has a negative reaction to the medicine (2,10).

OTC medicines are often assumed to be safe and not afforded the proper diligence. Even common drugs such as acetaminophen and ibuprofen can result in significant toxicity for infants and small children. Inaccurate dosing from the use of inaccurate measuring tools can result in illness or even death (2,3).

Cough and cold medications (CCM) are readily available OTC in the United States and are widely used to treat upper respiratory infection. These products are not safe for infants and young children and were withdrawn by the Consumer Healthcare Products Association for children less than two years of age in 2007 (4-6,8). The Food and Drug Administration (FDA) issued a public health advisory in 2008 stating these medications should not be used in children less than two years of age. The American Academy of Pediatrics (AAP) states that CCMs are not effective for children less than six years of age and their use can result in serious, adverse effects (7).

The medication record protects the person administering medication by documenting the process. The medication errors log can be reviewed and will point out what kind of intervention, if any, will be helpful in reducing the number of medication errors. Accounting for medications administered and thrown away is important for several reasons. It may assist a health professional in determining whether the child is actually getting the medicine, especially when the child is not getting better from treatment. Some medications are “controlled substances,” meaning that the medication is regulated by the federal government due to potential for abuse. Controlled substances include narcotic pain medicine, some behavior medications for ADHD, and some seizure medications. A prescribing health professional may need proper accounting for these types of medications to assure that requests for refills are because the medication was given to the patient and not used/abused by adults. Some medications, (i.e., antibiotics), can have a harmful affect on the environment if not disposed of properly.

For children with chronic health conditions or special health care needs, administering medications while the child is attending child care may be part of the child’s individualized family service plan (IFSP) or individualized education plan (IEP). Child care facilities must comply with the Americans with Disabilities Act.

COMMENTS
When a child care facility cannot return unused medication to the parent/guardian, the facility needs to dispose of the medication. An example of when medication cannot be returned is when a parent/guardian has removed the child from care and the facility cannot reach the parent/guardian to return the medication. Herbal and folk medicines and home remedies are not regulated and should not be given at child cares without a prescribing health professional’s order and complete pharmaceutical labeling. If they are given at home, the caregiver/teacher should be aware of their use and possible side effects.

A curriculum for child care providers on safe administration of medications in child care is available from the AAP at http://www.healthychildcare.org/HealthyFutures.html. A sample medication administration policy is located in Appendix AA: Medication Administration Packet.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
9.4.2.6 Contents of Medication Record
Appendix AA: Medication Administration Packet
REFERENCES
  1. North Carolina Child Care Health & Safety Resource Center. 2007. Steps to administering medication. http://www.healthychild
    carenc.org/PDFs/steps_admin_medication.pdf.
  2. American Academy of Pediatrics. 2009. Healthy futures: Medication administration in early education and child care settings. http://www.healthychildcare.org/HealthyFutures.html.
  3. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.
  4. American Academy of Pediatrics, Committee on Drugs. 2009. Policy statement: Acetaminophen toxicity in children. Pediatrics 123:1421-22.
  5. Vernacchio, L., J. Kelly, D. Kaufman, A. Mitchell. 2008. Cough and cold medication use by U.S. children, 1999-2006: Results from the Sloan Survey. Pediatrics 122:e323-29.
  6. Schaefer, M. K., N. Shehab, A. Cohen, D. S. Budnitz. 2008. Adverse events from cough and cold medicines in children. Pediatrics 121:783-87.
  7. Centers for Disease Control and Prevention. 2007. Infant deaths associated with cough and cold medications: Two states. MMWR 56:1-4.
  8. U.S. Food and Drug Administration. 2007. Nonperscription cough and cold medicine use in children. http://www.fda.gov/Safety/
    MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm152691.htm.
  9. Consumer Healthcare Products Association. Makers of OTC cough and cold medicines announce voluntary withdrawal of oral infant medicines. http://www.chpa-info.org/pressroom/10_11_07_OralInfantMedicines.aspx.
  10. Heschel, R. T., A. A. Crowley, S. S. Cohen. 2005. State policies regarding nursing delegation and medication administration in child care setttings: A case study. Policy, Politics, and Nurs Prac 6:86-98.
  11. Friedman, J. F., G. M. Lee, K. P. Kleinman, J. A. Finkelstein. 2004. Child care center policies and practices for management of ill children. Ambulatory Pediatrics 4:455-60.
  12. Sinkovits, H. S., M. W. Kelly, M. E. Ernst. 2003. Medication administration in day care centers for children. J Am Pharm Assoc 43:379-82.