Transcript Improving Safety and Quality in Medication Management in

A Systems Approach to Reducing
Risk and Strengthening Quality
in School Medication Management
Nancy Eichner, MUP, Senior Program Manager
Julia Graham Lear, PhD, Director
Center for Health & Health Care in Schools, GWU School of
Public Health and Health Services, NASBHC, June 17, 2005.
The Center for
Health and Health Care in Schools
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Being trained to give medication is not the critical
issue -- The critical issue is having time to give it right
and give the students the care they deserve.
Secretaries have a full-time job and the care we give
students is haphazard, not because we are not
responsible or do not want to give good care -- it’s
because we are already over-extended. The long and
short of it, we are an accident waiting to happen!
Elementary school secretary
Seattle Public Schools
March 29, 2001
The Center for
Health and Health Care in Schools
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Schools, Medicine, and Children:
Basic Facts
•In school year 2000 - 2001, 50 million children
between ages 5 and 19 attended elementary or
secondary school in the U.S.
•A significant number have health problems that
require medication or other medical treatment during
the school day.
•Federal, state and local laws mandate that schools
make care available.
•Assuring safe management of medications given
during the school day will require system changes.
The Center for
Health and Health Care in Schools
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Common Health Problems of
School-Age Children, 5 - 17, 1997
Asthma
6,720,000
% of
total
13%
3,073,000
6%
18,490,000
NA
Ever told had LD
4,496,000
8.7%
Ever told had ADD
3,252,000
6.3%
Ever told had
asthma
Asthma attack in
past 12 months
Hay fever, respiratory
allergies, other
allergies
Learning disabilities
The Center for
Health and Health Care in Schools
Number
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Policies & Practices Related to
Medication Administration
•64% of states and 94% of school districts have
requirements regarding school administration of
medications
•74% of schools have a medical supply cabinet with
a lock
•65% have a separate medicine cabinet with a lock
•57% have a refrigerator reserved for health
services
The Center for
Health and Health Care in Schools
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Staffing for Medication
Management in Schools
Current staff who provide meds in schools:
• School nurses: an estimated 70,000 for 115,000
elementary & secondary schools
• UAPs (unlicensed assistive personnel) includes
health aides as well as school secretaries.
Unknown number
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Health and Health Care in Schools
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State and District Required Mandates
Health
services
Admin. of
medications
% of
states
% of
districts
64.0
93.7
First aid
48.0
92.1
CPR
42.0
81.5
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Health and Health Care in Schools
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Legal Requirements - Federal
Section 504 of the Rehabilitation Act of 1973
Declares that discrimination on the basis of disability is
prohibited in federally funded programs.
Individuals with Disabilities Education Act, as amended
For students whose disabilities may interfere with
learning, school systems must make accommodations.
Americans with Disabilities Act (ADA) extends
protections of 504 to private schools.
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Health and Health Care in Schools
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Legal Requirements - States
Different approaches
•Generally admonitory rather than regulatory
language, e.g. “an effective medication policy will
assure etc.”
•Best practice recommendations, e.g. AL guidelines
for LEAs on medication administration
•Recommended rather than required language, e.g.
MN state law says “Drugs and medicine…must be
administered, to the extent possible, according to
school board procedures.”
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Health and Health Care in Schools
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Barriers to Safe, High Quality
Medication Management in School
• Until their child gets sick, most parents do not know
their school’s medication practices.
•Many school board members do not know their
system’s medication management practices.
•Health services generally receive limited attention from
school system policymakers.
•The people who know policies & practices -- school
nurses & other school staff -- have limited input into the
school system’s policy & budget process.
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Health and Health Care in Schools
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Improving Medication Management
Safety & Quality: Lessons From IOM
Studies
•Designing systems to prevent error by reducing
reliance on memory and vigilance.
•To design for safety means to think about work
hours, work loads, appropriate training and to have
systems that include procedures that make errors
visible and that in the case of error, mitigate harm.
The Center for
Health and Health Care in Schools
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Improving Medication Management Safety &
Quality: Applying Lessons from Crossing the
Quality Chasm
•System design using 80/20 principle: design for the usual, plan
for the unusual. Develop simple low-cost process for performing
routine work
Examples:
•Using photos attached to medications to assure accurate
student identification
•Using electronic entry of medication admin information to track
documentation & problems
•Designing system to improve safety requires a learning
environment, not a blame & reprisal culture
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Health and Health Care in Schools
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THE GOAL
To reduce errors and improve performance
in the administration of medications at
school for the more than 50 million
American children between ages 5 and 19
who attend an elementary or secondary
school in the United States
The Center for
Health and Health Care in Schools
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CHHCS Project on Medication
Management at School
• Funded by Agency for Healthcare Research
and Quality, Fall 2003 - Summer 2004
• Issue Brief
• Invitational workshop involving key
stakeholders
• Content: focus on systems issues -- policy
guidance, delegation, documentation, process,
security, and quality
• Case studies: comparison of two school health
programs (Boston, MA; Austin, TX)
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Key Points from Issue Brief
Assumptions we make in our approach to strengthening
medication management in schools are as follows:
• Research from IOM Reports: to Err is Human and
Crossing the Quality Chasm is applicable
• System development is the strategy for improving what
is done
• School environment impact your results – both physical
and social
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Key Points from Issue Brief
Systems to Reduce Risk—Factors to Address
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•
•
•
•
•
Policy
Delegation
Documentation
Process
Security
Quality
•
•
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•
Self-medication
Privacy
Prescribing
Standards
Communication
with medical
professionals
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Key Questions from Issue Brief
• Are these approaches to improving patient
safety, quality of care applicable to medication
management in schools?
• What research is needed to create a
knowledge base sufficient to make
recommendations for system changes?
• What are the downsides of assuming that a
safer system can be created when unlicensed
personnel perform medical functions?
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Key Questions from Issue Brief
• What are the politics that will affect the
ability of community, state, and national
institutions to implement any
recommendations?
• Are there strategies that could be
developed to build a foundation for
quality improvement in medication
management in school?
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Case Studies: Two City School
Districts & Their School Health
Services
• Boston
– 63,000 students
– Sch system managed
sch health program
– # SN: 93.5 FTE
– Students with IHPs 3.8%
– Direct student contacts,
721,300
– Medication assistance:
227,114
• Austin
– 78,000 students
– Children’s hospitalmanaged sch health
program
– # SN: 65 FTE
– UAPs: 52 FTE
– Direct student contacts,
543,259*
– Medication assistance:
188,519
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Case Studies: Two City School
Districts & Their School Health
Services
• Boston
– Episodic care 416,650
– Medication - 227,114
– Procedures - 44,369
– Screenings - 36,645
Total 721,300
• Austin
– Episodic care 338,489
– Medication - 187,897
– Screenings - 61,786
Total: 588,172
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Workshop Findings:
Barriers to Action
• Limited risk reduction work in pediatric ambulatory care
makes it hard to jumpstart system improvement efforts in
school-based medication management.
• Focus on staffing issues in school health make it difficult to
focus on other system components that might be
strengthened to improve medication management at school.
• Other important issues include: psychotropic drugs, data
collection & use, accountability & liability, parental
involvement.
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Workshop Findings:
Opportunities
• Develop criteria that could be used to identify measures or
standards for assessing safety of school medication
management practices.
• Focus on key areas such as the “hand-off” from community
provider to parent or parent to school.
• Engage community pharmacists in efforts to improve
medication management safety.
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Contact Information
The Center for Health and Health Care in Schools
2121 K Street, NW, Suite 250
Washington, DC 20037
202-466-3396
202-466-3467 fax
www.healthinschools.org
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Health and Health Care in Schools
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