INFECTION PREVENTION
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O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E | D E C E M B E R 2 0 1 4
If sinks, soap and paper towels are properly located and alcohol
hand rub dispensers are readily available, the number of changes
required to address hand hygiene is low. But if major construction
would be needed to add sinks and install alcohol dispensers, the need
for changes would be high. If your staff is well educated on the risks
associated with sharps injuries, and you've taken steps to prevent
them (using specially designed equipment, instituting "passing zones,"
conducting in-services), you'd score this a 0 or 1. If you haven't, it
might be a 2 or 3.
Adding up the scores
Add up the numbers and you get a clearer idea of where you should
be focusing your attention. High numbers suggest a higher priority.
Let's say the probability of a sharps injury is a 2 — fairly likely.
Additionally, the degree of risk is also a 2 (potential for permanent
harm). But let's assume you've gone to considerable lengths to
address the situation (1 point). The total would be 5.
Now let's say hand hygiene compliance is poor, based on your
observations (3 points). The potential harm is a 2 (though it could be
higher or lower depending on your procedures). Generally, you have
good product available and it's located in areas where it's convenient
to all levels of staff; it's just a matter of getting staff to use it. That's 1
more point, giving it a total of 6, and making it a higher priority.
Improvement strategies
Your risk assessment should be a springboard for action, leading to
both goals ("improve hand hygiene compliance" "reduce the risk of
SSIs") and measurable objectives. Measurable objectives should cite
specific results to be achieved over specified time periods: "Hand
