Infection Prevention and Control – Risk AssessmentSECTION: 14.22

Strength of Evidence Level: 1__RN__LPN/LVN__HHA

PURPOSE:

To provide general guidelines for completing an agency infection control risk assessment in order to minimize the risk of patients developing a healthcare associated infection (HAI).

CONSIDERATIONS:

  1. Completing a risk assessment is part of the infection prevention and control planning process.
  2. It is required by some regulatory bodies,e.g., The Joint Commission.
  3. Review risk analysis at least annually and whenever significant changes occur in geography, community environment, programs/services provided, population served and analysis of data.
  4. Agency leadersand direct and indirect patient staff should participate in the risk assessment process.

EQUIPMENT:

Computer

Phone for IP networking

Calculator

PROCEDURE:

  1. Form a risk assessment team.
  2. Identify areas of risk and potential impact on patients, staff and agency.
  3. Identify risks for acquiring and spreading infections based on the following:
  4. Geographic location, community and population served.
  5. Care, treatment or services provided.
  6. Identify risks for acquiring and spreading infections based on analysis of surveillance activities and other infection control data.
  7. Surveillance activities may address processes and/or outcomes.
  8. Surveillance activities used to identify risks pertaining to:
  9. Patients.
  10. Clinicians, volunteers and students.
  11. Visitors and families, as warranted.
  12. Evaluate each potential risk in each of the three categories of probability, impact and current systems. Add additional events as necessary.
  13. Issues to consider for probability include but are not limited to:
  14. Known risk.
  15. Historical data.
  16. Reports in the literature.
  17. Issues to consider for impact include but are not limited to:
  18. Threat to life and/or health.
  19. Disruption of services.
  20. Loss of function.
  21. Loss of community trust.
  22. Financial impact.
  23. Legal issues.
  24. Issues to consider for preparedness include but are not limited to:
  25. Status of current plans/implementation.
  26. Training status.
  27. Availability of backup systems.
  28. Community/public health resources
  29. (See Appendix A- Infection Prevention Program Risk Assessment Grid Sample.)

AFTER CARE:

  1. Prioritize the identified risks for acquiring and spreading infections and, based on the risks, develop the following:
  2. Goals (broad statements).
  3. Objectives (specific and measurable).
  4. Strategies (steps to take to achieve goals).
  5. Evaluation (how you will measure achievement of objectives)
  6. Progress (current measure and next steps)
  7. Develop annual Infection Control and Prevention Plan based on these risks.