Program Failure of Prevention Activities Hand Hygiene Respiratory Hygiene Staff Education Patient Education Basic Infection Prevention Standard Precautions/ PPE (Health,, Legal, safe injection practice high level disinfection practices Sterilization practices Failure to separate clean from dirty safe pharmacy practices Page 1
Policy and Procedure current policies or procedures Failure to follow established policy or procedure (Health,, Legal, Exposure Plans B/BF Exposure Control Plan respiratory protection plan Risk of exposure to TB Emergency Preparedness plan (exposure to infectious agents or diseases) Healthcare- Associated Infections surveillance process Page 2
Outbreaks (Health,, Legal, Sentinel Events Employee Health Staff Immunization Compliance with Annual Health Review Policy Risk of Needlestick/ Sharps Injury Environment acceptable environmental cleanliness Sterilization Monitoring Failure to Identify Construction Risks Page 3
Antimicrobial Stewardship useful antibiogram antimicrobial use guidelines monitoring program (Health,, Legal, feedback regarding monitoring results appropriate surgical prophylaxis culture to guide antimicrobial use Other Influenza Immunization Noncompliance in patients Page 4
(Health,, Legal, The Infection Prevention and Control (IP&C) Risk assessment grid is a visual tool to develop IP&C program priorities and stratify infection risks based on our location in the community, our patient population and the review of our previous IP&C 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 Prevention and Control committee. Team members included: Approved by Infection Prevention and 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 Page 5
Program Failure of Prevention Activities (Health,, Legal, Basic Infection Prevention Page 1
Policy and Procedure (Health,, Legal, Exposure Plans Healthcare- Associated Infections Page 2
Employee Health (Health,, Legal, Environment Antimicrobial Stewardship Page 3
(Health,, Legal, Other The Infection Prevention and Control (IP&C) Risk assessment grid is a visual tool to develop IP&C program priorities and stratify infection risks based on our location in the community, our patient population and the review of our previous IP&C 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 Prevention and Control committee. Team members included: 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 Page 4