Cory Sanfilippo is often mistaken for the school nurse by parents at Sutter Elementary School in Santa Clara County, California, where she works as a school secretary. "I always correct them," Sanfilippo says. But it seems to be a constant misconception. Sanfilippo takes her job seriously: She answers the phone, writes school reports and letters for the principal, responds to parents' questions, deals with children who've been sent to the office because they're misbehaving or have wet their pants, signs off on package deliveries -- and gives medication to students.

Because the school nurse is on campus only once a week, it falls on Sanfilippo to hand out medication to students and deal with emergencies. She's skilled in cardiopulmonary resuscitation, injecting epinephrine to prevent shock in food-allergic children, and has used her own familiarity with the care of a diabetic grandmother to help her respond to the needs of children with diabetes at school. But Sanfilippo is uncomfortable with the role she's been forced to assume.

"I'm lucky that we haven't had a near-death experience. My greatest fear is: Is today going to be the day?" says Sanfilippo.

On any given day, Sanfilippo will have to deal with five to 15 children coming to the office because they need their medication or they don't feel well or because there's an emergency. "We have asthma big time," she says. "We have some visually impaired this year and 13 students that have autism. We have severe allergies to milk and peanuts and bee stings, five or six kids with EpiPens (injection pens to prevent anaphylactic shock), and a couple of children with cancer in remission."

Hard-working and conscientious, Sanfilippo distributes medication, making sure that the children swallow their pills or get the right number of puffs of an asthma inhaler. It's at this point that she enters an unknown -- and dangerous -- zone: "I can tell if a child with asthma is having trouble breathing, but I cannot tell what stage of distress a child is in," Sanfilippo says.

Sanfilippo's worries are well grounded. Mistakes are more than three times as likely to occur when an unlicensed person and not a nurse is responsible, according to a 2000 University of Iowa survey, whose results were reported in the Journal of School Health. Unfortunately, the vast majority of school employees handing out medications have no medical background, the report continued. The randomized national survey of 649 school nurses in 49 states showed that more than 75 percent of school nurses had to delegate medication administration to school staff lacking medical training, referred to as "an unlicensed assistive personnel."

The types of errors included "missed doses, overdoses, giving the child the wrong medication or not writing down that medication had been given."

Seeing those problems first-hand is Juanita Hogan, a school nurse in Pittsburgh, Pa., who circulates among four to six schools each week. She has seen the risks to schoolchildren when medically untrained staff that work in her absence are at the helm: "I had a student on Ritalin [for ADHD] at a school I visited once a week," says Hogan, a nurse practitioner. "The following week he had a protrusion on his tongue," indicating he was on too high a dose. The doctor, she explains, should have been notified immediately that the medication was at a toxic level and should be stopped. "That was very dangerous," Hogan recalls. "The child could have had trouble swallowing, choking and breathing."

In another survey compiled by the California School Nurses Association in 2003, a nurse who covers eight schools had trained a school aide to hand out medication. After a student with a seizure disorder died, she looked at his medication card, noting in horror that the student wasn't called in by school staff to take his medication, as he was supposed to, and had missed seven out of 15 doses. "I saw this omission three weeks late when I checked his card," writes the nurse. "The parent had not been notified of the omissions. He had a seizure when home alone ... He hit his head on a sharp table corner and was found dead by his parents."

This crisis in school medication errors has received little publicity, although teachers have pleaded for help in state hearings. "I sat in a room and watched a teen pass away, " says Curtis Washington, a science teacher at Mills High School in Millbrae, Calif. Pausing to compose himself at the California State Board of Education hearing in February 2003, he recounts the death of a student who suddenly fell unconscious during badminton practice in 2001 -- there was no on-duty school nurse, and paramedics could not revive him. "Would that have been different if there was a school nurse?" Washington asks. "I don't know. But that's a question I have to live with.

"We talk about how we have to have qualified teachers," Washington continues, his voice rising. "If I mess up on a lesson, I could have a negative impact on a child's future, but if we mess up their medical care or their medication, that child may not even have a future."

It's hard to understand why healthcare services in schools would not be automatically guaranteed. In fact, laws and regulations on the issue are a tangled maze, differing from state to state and even district to district. Only Delaware and the District of Columbia, for example, require that there be at least one nurse for every 750 students. States also interpret federal mandates differently. In some states children with severe chronic health conditions and those with learning disabilities are covered by section 504 of the federal Rehabilitation Act, so that schools are required to provide them with health services. Other states allow a child's chronic health condition to be covered by section 504 only if that child also has a learning disability.

Even if schools try to maintain health services for students, many have been forced to make cuts in those services in order to pay for programs to meet the test scores demanded by the Bush administration's No Child Left Behind program. A recent report by the National Conference of State Legislatures, for example, said that "in the best-case scenario, federal funding marginally covers the cost of complying with the administrative processes." However, the February 2005 report continues, "states still face a separate set of costs to reach the law's standards of proficiency." If states choose not to comply with the law, they lose massive amounts of federal school funding.

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