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The Infection Prevention and Control Program Plan

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					                                                        Main Street Hospital
                                           Infection Control Risk Assessment Tool 2005

Completed by: ICP                                                               Date Completed:
Methodology:
Infection Control completed this risk assessment utilizing information available patterns/trends, high risk, problem prone issues,
trends in the community and other indicators.
Priorities were identified by selecting the two highest potential events in each category. Generally, priorities are those items scoring
a 10 or higher.
Although, all items have not been identified as priorities, they will still be considered as potential opportunities for improvement,
particularly those in which the Preparedness Score is 3.


               PRIORITES for 2005                                                           PROPOSED ACTION
POTENTIAL FOR INFECTION
                                                                                Improve pre-op antibiotic timing
                                                                                 compliance
Surgical Site Infection (SSI)                                                   Evaluate peri-op strategies to reduce
                                                                                 infections

                                                                                Maintain high compliance with oral care
                                                                                Investigate ET tube with continuous
                                                                                 suctioning
Vent Associated Pneumonia (VAP)                                                 Evaluate respiratory therapy practices in
                                                                                 light of current guidelines and
                                                                                 recommendations

EXPOSURE RELATED
                                                                                Write policy, coordinate with Emergency
                                                                                 Preparedness
Influx of Infectious Patients                                                   Address need for additional negative
                                                                                 pressure isolation areas (portable devices?)

Identification of Outbreak
                                                                                Write policy

PEOPLE
                                                                                Implement hand hygiene compliance
Hand Hygiene
                                                                                 monitor
                                                                                Improve hand hygiene compliance rates

ENVIRONMENT
                                                                                Write policy for handling utility failure
Utility Shutdown/Loss of Utilities                                               (water).

SUPPLIES
                                                                                Review housekeeping manual
                                                                                Inservice Housekeeping employees on
Improper Cleaning/Disinfection of environment                                    Infection Control practices
                                                                                Surveillance rounds with Housekeeping
                                                                                 Supervisor




2005 Annual Infection Control Risk Assessment
                                                                                                                                      1
       Completed Assessment Follows:

         Event                    Probability of                       Potential                    Potential Change in       Preparedness        Risk
                                   Occurrence                      Severity/Risk Level               Care, Treatment,                             Level
                                                                       of Failure                        Services



                           High     Med    Low     None       Life       Permanent   Temp   None   High   Mod   Low   None   Poor   Fair   Good
                                                           Threatening     Harm      Harm
                 Score:     3          2    1          0       3            2         1      0      3     2     1      0      3      2      1
POTENTIAL
INFECTION
Surgical Site Infection
                                       2                       3                                    3                                2             10
Vent Associated
Pneumonia
                                       2                       3                                    3                                2             10
Central Line Related
Blood Stream Infection
(CLBSI)
                                            1                  3                                    3                                2             9

C.difficile
                                            1                                         1                         1                    2             5
MRSA (hospital
acquired)                                   1                                         1                         1                           1      4
VRE (hospital
acquired)                                   1                                         1                         1                           1      4
EXPOSURE RELATED
Infection Incidents
Relate to Animals in                        1                                         1                         1                    1             4
Hospital
Emergency Mgmt
Procedure – Influx of                  2                       3                                    3                                2             10
Infectious Patients
Infectious Disease
Outbreak
                                            1                  3                                    3                         3                    10
COMMUNICATION
Lack of notification of
presence of HAI or
condition requiring
                                            1                                         1                   2                                 1      5
isolation (Admitted)
Lack of notification of
presence of HAI                             1                                         1                   2                                 1      5
(Internal Transfer)
Lack of notification of
employee with                          2                                              1                   2                          2             7
illness/disease
PEOPLE
Poor Hand Hygiene
Compliance
                            3                                  3                                    3                         3                    12
Sharps Injury (HCW)
                                            1                  3                                          2                                 1      7
Visitor with Reportable
Communicable                                1                                         1                         1                           1      4
Disease
Poor TB Screening
(Hospital)
                                            1                                         1                   2                                 1      5
Poor TB Screening
(LIP)
                                            1                                         1                   2                                 1      5
Inappropriate use of
Isolation
                                            1                                         1                   2                                 1      5
Ineffective Screening of
Employees/Contract/                         1                                         1                   2                                 1      5
Agency Staff
Ineffective Screening of
Volunteers
                                            1                                         1                   2                                 1      5
Ineffective Screening of
Students
                                            1                                         1                   2                                 1      5
Ineffective Fit Testing
(Hospital)
                                            1                                         1                   2                                 1      5
Ineffective Fit Testing
(LIP)
                                   2                                                  1                   2                                 1      6


       2005 Annual Infection Control Risk Assessment
                                                                                                                                                        2
        Event                       Probability of                      Potential                    Potential Change in       Preparedness        Risk
                                     Occurrence                     Severity/Risk Level               Care, Treatment,                             Level
                                                                        of Failure                        Services



                             High     Med   Low      None      Life       Permanent   Temp   None   High   Mod   Low   None   Poor   Fair   Good
                                                            Threatening     Harm      Harm
                  Score:      3        2     1         0        3            2         1      0      3     2     1      0      3      2      1
ENVIRONMENT
Inappropriate handling
of biohazard waste
                                             1                  3                                          2                                 1      7
Ineffective
preconstruction IC
Planning (meeting &
                                             1                               2                       3                                       1      7
risk assessment)
Ineffective notification
for applicable utilities
issues/shutdown
                                       2                                               1                   2                   3                    8
(HVAC, etc)
Ineffective notification
of cable installation (IS,             2                                               1                   2                          2             7
Biomed, phone, etc)
Major Biohazard Spill                        1                  3                                          2                                 1      7
Air Exchange &
Pressure Monitoring
Issue (isolation room,
                                       1                        3                                    3                                1             8
OR, other)
SUPPLIES/EQUIPMEN
T
Improper storage or
disposal of supplies
                                             1                                         1                         1                           1      4
Improper cleaning/
disinfection of
supplies/equipment/toy
                                             1                  3                                    3                                       1      8
s
Improper
cleaning/disinfection of               2                                     2                             2                          2             8
environment
Ineffective
reprocessing of                              1                               2                             2                                 1      6
disposable devices
Improper Sterilization
(including positive
biologicals) of
                                             1                  3                                    3                                       1      8
supplies/equipment
Positive Dialysis
Culture
                                             1                                         1                   2                                 1      5




       2005 Annual Infection Control Risk Assessment
                                                                                                                                                        3

				
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Description: The Infection Prevention and Control Program Plan