Southeastern Regional Medical Center 2011 -2012 Infection Prevention and Control Risk Assessment Infection events
INFECTION EVENT PROBABILITY OF OCCURRENCE LEVEL OF HARM FROM EVENT IMPACT ON CARE READINESS TO PREVENT RISK LEVEL
(How likely is this to occur?) (What wouldModerate
Serious be the most likely?)
Temp. (Will new treatment/care be needed for resident(Are processes/resources in place (tScores ≥ 8 are considered highest priority for improvement efforts.)
Score High Med. Low None Harm Harm Harm None High Med. Low None Poor Fair Good
3 2 1 0 3 2 1 0 3 2 1 0 3 2 1
Facility-onset Infections(s)
Device- or care-related
Catheter-associated urinary tract infection (CAUTI)
Central line-associated bloodstream infection (CLABSI)
Tracheostomy-associated respiratory infection
Percutaneous-gastrostomy insertion site infection
Wound infection
Other (specify):
Resident-related
Symptomatic urinary tract infection (SUTI)
Pneumonia
Cellulitis/soft tissue
Clostridioides difficileinfection
Tuberculosis*
Other (specify):
Outbreak-related
Influenza*
Other viral respiratory pathogens*
Norovirus gastroenteritis*
Bacterial gastroenteritis (e.g.,Salmonella, Shigella)
Scabies
Conjunctivitis
Group A Streptococcus*
MDRO
Other (specify):
* Risk assessment should take into account the frequncy of this disease in the community as part of determining probability of occurrence. Data from State/local health department may be informative.
Date Prepared:
Adapted from https://spice.unc.edu/resources/template-risk-assessment-for-ltc/
1
IPC PRACTICE FAILURES PROBABILITY OF OCCURRENCE IMPACT ON RESIDENT/STAFF SAFETY CAPACITY TO DETECT READINESS TO PREVENT RISK LEVEL
(How likely is this to occur?) (Will this failure directly impact safety?) (Are processes in place to identify this (Are policies, procedures, and resources
(Scores ≥ 8 are considered highest priority for improvement efforts.)
Score High Med. Low None High Med. Low None Poor Fair Good Poor Fair Good
3 2 1 0 3 2 1 0 3 2 1 3 2 1
Care activity
Lack of accessible alcohol-based hand rub
Lack of accessible personal protective equipment (PPE)
Inappropriate selection and use of PPE
Inadequate staff adherence to hand hygiene
Inadequate staff adherence to glove and gown use when resident in Contact
Inadequate staff adherence to facemask use when resident in Droplet Precautions
Precautions
Other (specify):________________
Other (specify):________________
Occupational health
Low influenza immunization rates among staff
Lack of notification of employee illness or working sick
Low compliance with annual tuberculosis (TB) screening among staff
Other (specify):________________
Resident/visitor health
Low rates of TB screening among new resident admissions
Low rate of resident acceptance of influenza immunization
Low rate of resident acceptance of pneumococcal immunization
Visitors entering facility when ill
Lack of notification to visitors during facility outbreaks
Inadequate resident/visitor education on facility hand hygiene policies
Inadequate resident/visitor education on facility respiratory etiquette policies
Other (specify):________________
Environment
Lack of access to U.S. Environmental Protection Agency (EPA)-registered
Lack of access
products to EPA-registered
for routine products with sporicidal activity for cleaning and
cleaning and disinfection
disinfection (e.g., for C. difficile)
Inadequate cleaning and disinfection of high touch surfaces in resident room
Inadequate terminal cleaning and disinfection of resident rooms
Inadequate cleaning and disinfection of resident common areas
Other (specify):________________
Medical Devices and Equipment
Improper handling of medications and injection equipment (e.g., reuse of syringes)
Lack of access to single-use, auto-disabling fingerstick devices
Inappropriate sharing of devices labeled for single-patient use
Improper cleaning and disinfection of point-of-care devices (e.g., blood glucose
meter) between residents
Improper cleaning and disinfection of shared equipment (e.g., blood pressure cuff)
Lack of separation
between residents between clean supplies and dirty/contaminated medical
Improper storage and/or transport of linen
supplies
Other (specify):________________
Antibiotic Stewardship
Lack of leadership support for antibiotic stewardship
Inadequate written policies guiding antibiotic use
Unable to obtain antibiotic usage report from pharmacy
Unable to obtain report summarizing antibiotic resistance patterns (e.g.,
Inadequate resident/family education on facility antibiotic stewardship policies
antibiogram)
Other (specify):________________
Date Prepared:
Adapted from https://spice.unc.edu/resources/template-risk-assessment-for-ltc/
