Before a patient receives an injection of insulin from a registered nurse at Akron Children's Hospital, a second registered nurse must agree the proper dose has been drawn.
If a diabetic student needs an insulin shot at school without a nurse, it might fall to the secretary to give it.
''I have to have two R.N. signatures that we've eyeballed and we both agree that this is giving the right dose,'' said Michele Wilmoth, the hospital's nurse manager of School Health Services. ''In the school setting, it's like, who's even looking? Insulin! You could die.''
The potential for error in a school is higher than in a hospital because schools aren't bound by the same rules, but a new Ohio law that took effect July 1 aims to reduce medication mistakes.
The change, included in former Gov. Ted Strickland's two-year budget, requires that school staffers who are not licensed health professionals be trained before they can administer drugs.
Children's Hospital has been instructing school officials since last spring on the basics of making sure the right kid gets the right dose of the right medicine at the right time using the right method.
The three-hour training emphasizes how to handle routine and emergency situations involving students with diabetes, asthma, allergies and seizure disorders.
Children's has trained 330 school employees so far, including the Hudson staff, which went through training Friday.
Principals can designate who is allowed to administer medicines in a school, but secretaries are the most likely when a nurse isn't around, according to the Ohio Department of Health.
Typically, they're helping kids take an oral medicine, but in an emergency, the secretary might have to help a child use an inhaler to stop an asthma attack.
Or give an epinephrine injection if a child is having an allergic reaction.
Or inject Glucagon to rapidly boost blood sugar in an unconscious child.
Or insert a lubricated syringe of rectal Valium a gel with powerful medicine and precise instructions about how to deliver it to stop a child's seizures.
Parents of children with chronic conditions routinely have to give medicines at home, and they sometimes get it wrong.
A 2007 study of pediatric patients cited by the U.S. Department of Health and Human Services found that 70 percent of preventable medication errors were the result of mistakes in giving the drugs, mostly by the children's parents.
Schools take over that duty for much of a child's day.
Nearly 6 percent of school children in the United States receive medication every school day, according to a 2006 article in the American Journal of Health-System Pharmacy. In Ohio, that would be about 70,000 kids.
The same article cited a nationwide survey of school nurses who reported that the error rate was three times higher when someone other than a nurse was handing out the meds.
Author Philip Johnson is pharmacy advocacy director at the Moffitt Cancer Center at the University of South Florida. He has made reducing medication errors in schools a second professional passion because he has a son with asthma. He wrote a manual on administering drugs that is used in Florida schools and several other states.
''It is rare for a child to die from a medication error in school, but when it does happen, it is usually related to medication used for seizure disorders, specifically when the dose is changed by the physician and that information is not known to the school,'' Johnson said.
He said the most common mistake in schools occurs when a child doesn't get the medication at all.
''Most schools don't consider that an error, but it is very much an error,'' Johnson said.
Diabetes and asthma are among the chronic conditions that require careful attention to medication.
''If you don't have the right amount of sugar and oxygen in your brain, one, you're not going to pay attention in class, so your grades are going to be affected,'' Johnson said. ''Two, you're going to be more clumsy on the playground, and there's a high correlation of playground accidents.''
Parents sometimes depend on the schools to take care of daily medications, which puts a lot of pressure on schools to get it right.
''Twenty-three percent of the kids in Florida two years ago relied on the school Monday through Friday as the only source of food and medication for their child,'' Johnson said. ''They drop them off in the preschool program. Mom and Dad both work. They pick them up afterwards. They expect them to have their medication and be fed. And Florida is not an atypical state. That's absolutely scary.''
Providing health care
Wilmoth at Children's Hospital knows that her staff of 25 registered nurses and 125 medical assistants and health aides in 131 Summit and Portage county schools are often the primary medical providers for many children.
She recalls a child last year who had fallen off a skateboard and was told to get help the next day from the school nurse.
''This kid had a humongous scrape down the whole back,'' Wilmoth said. ''The parents had taped a paper towel over it and said go see the school nurse the next day. So, yeah, we're it sometimes.''
Children's has two registered nurses who work with 51 health aides in 51 buildings in the Akron district. Last year, the nursing staff administered about 35,000 doses of medicine in Akron middle schools and elementary schools. They expect the number to rise, because this year they're working in the high schools, too.
The hospital added Kent City Schools this year and contracts with Cuyahoga Falls, Coventry, Copley-Fairlawn, Hudson, Stow-Munroe Falls and Woodridge.
But those schools also are sending employees for training to cover situations when a nurse or health aide isn't available.
Akron-based charter school operator Summit Academy Management was grateful that Children's was willing to train 125 employees from its schools all over the state.
''The new law affected us because it was either we had to get the training or we had to have nurses in our schools,'' said Katherine Hrbolich, an administrator with Summit Academy Management. ''Some of our schools, we only have maybe 60 students, so financially, the cost of nurses today, their hourly wage, would have been a very big hardship on us. So we are just thankful that the law did say that we could have this training.''
Errors surprise trainers
Wilmoth said the trainers have been surprised to see errors even when practicing simple procedures like pouring a liquid medication. The cup should be placed on a table or counter. The liquid's surface forms a U shape in the cup with the sides higher than the middle. The correct dose is where the bottom of the U reaches the proper line on the cup.
''We thought, well, oral medications, how hard is it going to be?'' Wilmoth said. ''They weren't using the right measuring cup. They weren't getting down and eyeballing where the line is.''
Trainers also talk about asthma inhalers, which are filled with a certain number of doses that must be counted off to know when the inhaler is empty.
''It will make that sound and you'll think medicine is left in there and it's actually out of medicine,'' Wilmoth said. ''It's just blowing out air. There's no medicine in it.''
Nothing in the law requires the training to be annual, but Wilmoth thinks that would be a good idea, especially to brush up on procedures that aren't commonly practiced.
''I taught you about how to do rectal Valium last year and you never had to use it, knock on wood,'' Wilmoth said. ''Then you come around next year, it would be good to have a refresher on that.''
John Higgins can be reached at 330-996-3792 or firstname.lastname@example.org. Read the education blog at http://education.ohio.com/.