The Annual Infection Prevention Risk
Assessment, Plan & Review
Learning objectives:
● Understand the interconnected, cyclical relationship between the annual risk assessment,
annual infection prevention plan and the annual evaluation.
● Confidently conduct a risk assessment with a multidisciplinary team.
● Create prioritized goals directly related to the risk assessment.
● Summarize your program’s accomplishments and opportunities in an annual evaluation.
The infection prevention and control plan (IPC) should include a goal for reducing the risk of
infection associated with each of these identified risks, a measurable objective for each goal, and
evidence-based strategies for meeting each of these objectives. The Plan should also identify the
personnel responsible for implementing the strategies and include mechanisms for evaluating the
effectiveness of meeting the infection surveillance, prevention and control (ISPC) plan’s
objectives.
Definition:
A risk assessment is the combined effort of identifying and analyzing potential (future)
events that may negatively impact individuals, assets, and/or the environment (i.e. hazard
analysis); and making judgments "on the tolerability of the risk on the basis of a risk analysis"
while considering influencing factors (i.e. risk evaluation).
The risk assessment process:
The HSE’s recommended steps to risk assessment are:
• Identify the hazards
• Identify the possible consequences
• Estimate the likelihood of the possible consequences
• Estimate the risk
• Evaluate the risk
• Record the findings
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Assessment Process:
1. Convene a team to conduct the risk assessment.
2. Identify potential risk factors in each of the following categories:
• Community and populations served
• Potential for specific infection
• Treatment and care practices
• Instrument and medical device cleaning, disinfection and handling
• Environment of care
• Emergency management
• Others identified by the organization
3. Assess and score each potential risk factor based on the following:
a. Potential impact of the event/condition on patients and personnel, determined by
evaluating the potential for patient illness, injury, infection, death, need for admission
to an inpatient facility; the potential for personnel illness, injury, infection, shortage;
potential to impact the organization’s ability to function/remain open; and degree of
clinical and financial impact.
b. Probability of the event/condition occurring determined by evaluating the risk of
the potential threat actually occurring. Information regarding historical data, infection
surveillance data, the scope of services provided by the facility, and the environment
of the surrounding area (topography, interstate roads, chemical plants, railroad, ports,
etc.) are considered when determining this score.
c. Organization’s preparedness to deal with the event/condition determined by
considering policies and procedures already in place, staff experience and response to
actual situations, and available services and equipment.
4. After risk scores are assigned in the three assessment groups, total the numbers in each group
to provide a numerical risk level for each event/ condition.
5. Rank the events/conditions from the highest to lowest score in the table provided. Select the
risks with the highest scores for priority focus for developing the annual ISPC Plan.
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NOTE: Some events/conditions with a lower score may be selected because they are an
accreditation or regulatory requirement.
The risk assessment and ISPC Plan should be reviewed and approved by the organization’s
quality assurance and performance improvement committee (or other designated committee).
The risk assessment and ISPC Plan should be reviewed annually (and sooner if circumstances
change).
The following personnel conducted the risk assessment:
The group identified, assessed, and scored each potential risk factor based on the following:
1. Potential impact of the event/condition on patients and personnel, determined by
evaluating the potential for patient illness, injury, infection, death, need for admission to
an inpatient facility; the potential for personnel illness, injury, infection, shortage;
potential to impact the organization’s ability to function/remain open; and degree of
clinical and financial impact.
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2. Probability of the event/condition occurring, determined by evaluating the risk of the
potential threat actually occurring. Information regarding historical data, infection
surveillance data, the scope of services provided by the facility, the environment of the
surrounding area (topography, interstate roads, chemical plants, railroad, ports, etc.), and
health department data, are considered when determining this score.
3. Organization’s preparedness to deal with the event/condition, determined by
considering policies and procedures already in place, staff experience and response to
actual situations, and available services and equipment.
Ranking of Scores
After risk scores are assigned in the three assessment groups, the numbers in each group were
totaled to provide a numerical risk level for each event/condition. The numerical risk level can
range from 0 (lowest vulnerability) to 9 (highest vulnerability). The risk factors (i.e.,
events/conditions) were then ranked from highest to lowest risk level in the table below. The
risks with the highest scores will be used for priority focus for developing the annual ISPC Plan.
NOTE: Some events/conditions with a lower score may be selected because they are an
accreditation or regulatory requirement or can be quickly and easily implemented.
1. Potential impact of the event/condition on patients and personnel: determined by
evaluating the potential for patient illness, injury, infection, death, need for admission to an
inpatient facility; the potential for personnel illness, injury, infection, shortage; potential to
impact the organization’s ability to function/remain open; and degree of clinical and financial
impact.
2. Probability of the event/condition occurring: determined by evaluating the risk of the
potential threat actually occurring. Information regarding historical data, infection
surveillance data, the scope of services provided by the facility, and the environment of the
surrounding area (topography, interstate roads, chemical plants, railroad, ports, etc.) are
considered when determining this score.
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3. Organization’s preparedness to deal with the event/condition: determined by considering
policies and procedures already in place, staff experience and response to actual situations,
and available services and equipment.
Risk Assessment for the Infection Surveillance, Prevention and Control (ISPC)
Program
What is potential impact of What is organization’s
What is probability of Numerical
Event or Condition event/condition on patients preparedness to deal with
event/condition occurring? risk level
and staff? this event/condition?
High Med Low None High Med Low None None Poor Fair Good
Total
(3) (2) (1) (0) (3) (2) (1) (0) (3) (2) (1) (0)
COMMUNITY & POPULATIONS SERVED:
EMERGING INFECTIOUS
DISEASE
POTENTIAL FOR SPECIFIC INFECTION:
CARE PRACTICES:
INSTRUMENT & MEDICAL DEVICE CLEANING, DISINFECTION & HANDLING
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What is potential impact of What is organization’s
What is probability of Numerical
Event or Condition event/condition on patients preparedness to deal with
event/condition occurring? risk level
and staff? this event/condition?
High Med Low None High Med Low None None Poor Fair Good
Total
(3) (2) (1) (0) (3) (2) (1) (0) (3) (2) (1) (0)
ENVIRONMENT OF CARE:
EMERGENCY MANAGEMENT:
OTHER:
Infection Control Plan
OBJECTIVE
RISK EVENT/ CONDITION GOAL (measurable, includes
timeframe for completion)
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Goals and Objectives
OBJECTIVE IMPLEMENTATION
(measurable,
ISK EVENT/
GOAL includes STRATEGIES
CONDITION
timeframe for Respon-
completion) Method for Evaluating
sible
Effectiveness
Person(s)