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CE Article: Risk assessments: The catch-all for hazard analysis* 

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No matter the size of your facility, the risk assessment drives your goals

Learning objectives:

After reading this article, you will be able to:


  •  Illustrate the parameters of a risk assessment
  •  Recognize how to set goals to reduce infections
  •  Explain the importance of documentation

“Do a risk assessment.” That’s the answer most frequently heard in response to questions regarding safety or infection control (IC.)

The risk assessment is a simple but effective tool to evaluate any number of risks stemming from worker protection, facility design requirements, or patient safety. But for whatever reason, the risk assessment elicits panic and fear among those who may not be familiar with the process, the documentation, or the analysis of risks.

“When they have some sort of situation or issue and I tell them they need to do a risk assessment, and the dread that comes over their face, you almost swear I was killing their first-born kid,” says Earl Williams, HSP-M, safety specialist at Advocate Health Care in Normal, IL. “And oftentimes they don’t seem to understand the difference between a risk assessment and a risk analysis.”

However, the risk assessment is evaluated in all areas of the hospitals during a Joint Commission survey, and it’s required annually for evaluation of your IC program.  

Although the assessment itself is a strong, reliable tool, Williams believes it signifies an area of healthcare that is weak, in the sense that some facilities do not use the assessment appropriately—assuming they use it at all.

But once you know the basics of a risk assessment, the rest follows easily, and the same procedure can be repeated with varying considerations, so you’ll be able to determine the severity of risks present in every part of your facility and simultaneously adhere to the standards that apply to your facility while developing a workable plan of action.

Where to begin

Whether you are conducting a risk assessment for employee protection measures during a certain procedure or a particular infection risk to your patient population, the assessment provides a unique look at your individual facility, says Libby Chinnes, RN, BSC, CIC, consultant and owner of IC Solutions, LLC, in Mount Pleasant, SC.

“A risk assessment is really a neat tool because it lets us look at how our organizations are unique,” Chinnes says. “It looks at what is different about my organization from your organization, whether they are two hospitals or two ambulatory surgery centers or whatever.”

It’s also an objective review of your procedures with the safety of the healthcare worker in mind, says John Schaefer, MSF, CIH, HEM, CPEA, associate director of health safety and environment for the Johns Hopkins University, Hospital and Health System in Baltimore.

“A risk assessment is the outside look of the work environment,” Schaefer says. “Very honestly, it’s the third person looking from outside to see exactly what is going on.”

A risk assessment will serve as a basis for your annual infection prevention and control plan by aiding in identifying your at-risk populations and procedures and helping to focus your surveillance efforts on the most important risks in your facility.

You may also want to take a close look at elevated risks for certain infections. If you have seen recent outbreaks of MRSA, for example, your risk assessment may push MRSA prevention efforts higher on your list of priorities.

 To read more about MRSA prevention in the healthcare setting, click here.

Parameters to consider

According to Williams, although each risk assessment is unique, there are a number of general parameters to consider during each one:


  • Applicable regulations. For any particular risk, what regulations provide guidance regarding the protective measures you should have in place? If it’s a fire issue, look to the Life Safety Code®. If it’s an employee issue, look to OSHA. If you are an accredited organization, consider Joint Commission or CMS standards.
  • Exposure. This can be considered in a variety of ways. Risk of employee exposure to an infectious disease can involve precautions using personal protective equipment or safe work practices, for example. What is the employee being exposed to and how can it be avoided?
  • Population/age group. A facility that chiefly serves children may have different risks than a facility that serves mostly senior citizens. For example, if you’re a women and children’s hospital with a neonatal ICU, your risks may be vastly different from an ambulatory surgery center that deals with less complex patients.  
  • History. Does your facility have a history of problems with a particular issue? For example, is there a history of TB outbreaks in your community that could affect the patient population?

To read more about developing a response team for TB outbreaks, click here.

  • Geography. Chinnes says because she is in the southeast of the United States, she always considers the effect of hurricanes or tropical storms. “I look at things like what would happen if we don’t have water or electricity,” she says. “What would happen to staffing if people couldn’t get in?”

Ultimately, there is no set amount of parameters to consider, says Williams. Instead, you need to make sure you’re looking at the issue from every angle.

“It’s not a magic number,” he says. “Each issue would dictate what parameters you look at.”

Prioritize your risks

If you’re a larger facility, once you do your risk assessment you’ll likely find that you have too many risks to address given your level of staff support. That’s why it’s important to be able to prioritize your risks and focus on those with negative outcomes that would disrupt your facility the most.

“You could say, ‘Okay, we have all these risks,’ and you could name 25, but if you’re the only one in a 150-bed hospital, then you’re not going to be able to follow 25 things through surveillance, most likely,” Chinnes says. “So you’re going to have to prioritize and narrow it down to say, ‘What are my top three or top five and how can I cover these with the resources I have?’ That’s when you get creative.”

Focusing on four or five risks also allows you to set goals for each one so you can show a surveyor—and yourself—how your program has progressed.

Document your assessment

Documentation of the risk assessment is the most important step in proving to inspectors (and to yourself) that you’ve completed the proper evaluation and taken appropriate actions.

Documenting a risk assessment can prevent an OSHA citation, Williams says. In one particular instance his laboratory administration wanted to remove an emergency shower from a laboratory, which is required by OSHA when working with corrosive substances. Williams looked at where it was located, the amount of chemicals involved, and the likelihood of a spill that would require a shower. He discovered there was less than a cup of corrosive material that was handled in a nearby hood. The lab also had a small hose nearby that could be used in case there was a spill.

 Determining hazard severity

There are a number of hazards within any healthcare facility, but the trick is to determine just how severe each hazard may be to your employees and to your patient population.

Earl Williams, HSP-M, safety specialist at Advocate Health Care in Normal, IL, uses a simple formula that assigns a score to each risk assessment. This allows you to prioritize your precautions and focus on the highest-risk activities.


  • First, consider the severity of the hazard and assign a score on a scale of 1–5. A score of 5 would be a very high-severity hazard causing multiple deaths and widespread destruction, such as a fire. A score of 1 would be a hazard that would result in a very minor injury, such as a scrape or a bruise, with no business disruption.
  • Next, consider the likelihood of the hazard on a scale of 1–5. A score of 5 would be “inevitable,” meaning if work were to continue as is, there would be 100% certainty of an accident occurring (e.g., a broken stair, exposed electrical conductors). A score of 1 would be a remote possibility that something would happen under freak conditions.
  • Multiply the two numbers together to obtain your “risk rating”:

- 1–4: Acceptable risk
- 5–9: Moderate risk
- 10–15: High risk
- 16–25: Unacceptable risk

“If it’s a low number, I’m probably not going to do too much,” Williams says. “If it’s a high number, I’ll do a lot more. If it’s an extremely high number, that’s basically an extremely high risk and I have to do something today.”

Click here to learn more about the relationship between risk and hazard.

Setting goals to minimize risks

Once you have determined your IC risks and prioritized them, The Joint Commission requires you to establish goals for each risk.

These goals must involve at least the following four objectives:


  • Limiting unprotected exposure to pathogens
  • Improving compliance with hand hygiene
  • Limiting transmission of infections associated with procedures
  • Limiting transmission of infections associated with equipment and devices

You should also set goals that are reasonable but can actually improve care, says Libby Chinnes, RN, BSC, CIC, consultant and owner of IC Solutions, LLC, in Mount Pleasant, SC. Don’t forget to include specific strategies that will help you achieve those goals, and note how you will evaluate each one.

Source: Briefings on Infection Control, September 2010




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