Fillable Printable Risk Assessment for Infection Prevention and Control
Fillable Printable Risk Assessment for Infection Prevention and Control
Risk Assessment for Infection Prevention and Control
Infection Control Program Risk Assessment
2008
Program
Components
Probability
Risk/
Impact
Current
Systems
Score
Expect it Likely Maybe Rare Never Loss of
life/limb/
function
Temp
loss of
Function
Inpatient
Care
Needed
Moderate
Clinical/
Financial
Minimal
Clinical/
Financial
None Poor Fair Good Solid
4 3 2 1 0 5 4 3 2 1 5 4 3 2 1
Failure of
Prevention
Activities
Lack of Hand
Hygiene
Lack of
Respiratory
Hygiene
Lack of Staff
Education
Lack of Patient
Education
Basic Infection
Prevention
Lack of Standard
Precautions/ PPE
Lack of safe
pharmacy
compounding
practice
Lack of high level
disinfection
practices
Lack of
Sterilization
practices
Failure to
separate clean
from dirty
(Health, Financial, Legal,
Regulatory)
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Infection Control Program Risk Assessment
2008
Program
Components
Probability
Risk/
Impact
Current
Systems
Score
Expect it Likely Maybe Rare Never Loss of
life/limb/
function
Temp
loss of
Function
Inpatient
Care
Needed
Moderate
Clinical/
Financial
Minimal
Clinical/
Financial
None Poor Fair Good Solid
4 3 2 1 0 5 4 3 2 1 5 4 3 2 1
(Health, Financial, Legal,
Regulatory)
Failure to safe
injection practices
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Infection Control Program Risk Assessment
2008
Program
Components
Probability
Risk/
Impact
Current
Systems
Score
Expect it Likely Maybe Rare Never Loss of
life/limb/
function
Temp
loss of
Function
Inpatient
Care
Needed
Moderate
Clinical/
Financial
Minimal
Clinical/
Financial
None Poor Fair Good Solid
4 3 2 1 0 5 4 3 2 1 5 4 3 2 1
(Health, Financial, Legal,
Regulatory)
Policy and
Procedure
Lack of current
policies or
procedures
Failure to follow
established policy
or procedure
Exposure Plans
Lack of B/BF
Exposure Control
Plan
Lack of respiratory
protection plan
Risk of exposure
to TB
Lack of
Emergency
Preparedness
plan (exposure to
infectious agents
or diseases)
Healthcare-
Associated
Infections
Lack of
surveillance
process
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Infection Control Program Risk Assessment
2008
Program
Components
Probability
Risk/
Impact
Current
Systems
Score
Expect it Likely Maybe Rare Never Loss of
life/limb/
function
Temp
loss of
Function
Inpatient
Care
Needed
Moderate
Clinical/
Financial
Minimal
Clinical/
Financial
None Poor Fair Good Solid
4 3 2 1 0 5 4 3 2 1 5 4 3 2 1
(Health, Financial, Legal,
Regulatory)
Outbreaks
Sentinel Events
Employee Health
Lack of Staff
Immunization
Lack of
Compliance with
Annual Health
Review Policy
Risk of
Needlestick/
Sharps Injury
Environment
Lack of
acceptable
environmental
cleanliness
Lack of
Sterilization
Monitoring
Failure to Identify
Construction
Risks
Antimicrobial
Stewardship
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Infection Control Program Risk Assessment
2008
Program
Components
Probability
Risk/
Impact
Current
Systems
Score
Expect it Likely Maybe Rare Never Loss of
life/limb/
function
Temp
loss of
Function
Inpatient
Care
Needed
Moderate
Clinical/
Financial
Minimal
Clinical/
Financial
None Poor Fair Good Solid
4 3 2 1 0 5 4 3 2 1 5 4 3 2 1
(Health, Financial, Legal,
Regulatory)
Lack of useful
antibiogram
Lack of
antimicrobial use
guidelines
Lack of monitoring
program
Lack of feedback
regarding
monitoring results
Lack of
appropriate
surgical
prophylaxis
Lack of culture to
guide
antimicrobial use
Other
Influenza
Immunization Non-
compliance in
patients
The Infection Control (IC) Risk assessment grid is a visual tool to develop IC program priorities and stratify infection risks based on our
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Infection Control Program Risk Assessment
2008
Program
Components
Probability
Risk/
Impact
Current
Systems
Score
Expect it Likely Maybe Rare Never Loss of
life/limb/
function
Temp
loss of
Function
Inpatient
Care
Needed
Moderate
Clinical/
Financial
Minimal
Clinical/
Financial
None Poor Fair Good Solid
4 3 2 1 0 5 4 3 2 1 5 4 3 2 1
(Health, Financial, Legal,
Regulatory)
location in the community, our patient population and the review of our previous IC data analysis. The annual IC Plan is developed based on
these risks.
The IC Risk assessment is an ongoing, continual process. A more focused review is done on an annual basis after reviewing the quarterly
and annual reports with the Infection Control committee.
Approved by Infection Control Committee: ____________________________
Submitted by:
Form based on information provided by Terrie Lee RN MS MPH CIC, Director, Epidemiology and Employee Health, Charleston Area Medical
Center, Charleston WV
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