醫(yī)療院感風險分級評估表模板一、評估表的核心構(gòu)成與說明本評估表模板旨在全面、系統(tǒng)地評估醫(yī)療機構(gòu)或特定科室、特定操作流程中存在的院感風險。它并非一成不變的教條，各單位應(yīng)結(jié)合自身特點（如規(guī)模、?？铺厣?、患者群體、現(xiàn)有資源等）進行適當調(diào)整與細化。醫(yī)療院感風險分級評估表評估維度評估指標評估要點/描述性選項(可多選或單選，根據(jù)指標特性)分值/權(quán)重(示例)實際得分/選擇備注與說明:---------------:-------------------------------------------:----------------------------------------------:---------------:------------:----------------------------**一、感染發(fā)生的可能性**1.患者因素a.易感人群比例（如老年、嬰幼兒、免疫低下者）高/中/低結(jié)合科室收治患者特征b.基礎(chǔ)疾病嚴重程度復(fù)雜/一般/簡單如多器官功能衰竭、糖尿病等2.病原體因素a.常見病原體耐藥性水平高耐藥/多重耐藥/敏感參考本院/本科室微生物監(jiān)測數(shù)據(jù)b.病原體傳播力強/中/弱如呼吸道傳染病、接觸傳播等3.診療操作與技術(shù)因素a.侵入性操作頻率與類型高風險操作多/一般/少如手術(shù)、中心靜脈置管、呼吸機b.無菌技術(shù)操作規(guī)程執(zhí)行依從性優(yōu)/良/中/差基于日常監(jiān)督與監(jiān)測結(jié)果c.醫(yī)療器械/物品清潔消毒滅菌效果可靠/基本可靠/需關(guān)注結(jié)合監(jiān)測合格率4.環(huán)境與流程因素a.手衛(wèi)生設(shè)施配備與手衛(wèi)生依從性充足/不足；高/中/低b.環(huán)境清潔與消毒頻率及效果規(guī)范/不規(guī)范；好/一般/差c.醫(yī)療廢物管理規(guī)范性規(guī)范/需改進d.通風與空氣凈化效果良好/一般/較差尤其針對空氣傳播風險區(qū)域**二、后果的嚴重性**1.對患者健康影響a.可能導(dǎo)致的感染類型及嚴重程度致命/嚴重并發(fā)癥/輕微/無癥狀b.對患者預(yù)后及住院時間的潛在影響顯著延長/略有延長/無影響2.對醫(yī)療秩序與資源影響a.可能引發(fā)暴發(fā)或聚集性病例的風險高/中/低b.隔離與額外治療所需資源消耗高/中/低3.對機構(gòu)聲譽與法律風險a.潛在的醫(yī)療糾紛與投訴風險高/中/低b.對機構(gòu)品牌形象的負面影響嚴重/一般/輕微**三、現(xiàn)有防控措施的有效性**1.制度建設(shè)與培訓a.相關(guān)SOP的完善與更新及時性完善/基本完善/缺失b.醫(yī)護人員院感知識與技能掌握程度熟練/基本掌握/不足結(jié)合培訓考核結(jié)果2.監(jiān)測與反饋機制a.院感病例監(jiān)測的敏感性與及時性高/中/低b.問題發(fā)現(xiàn)與整改的閉環(huán)管理效果有效/部分有效/無效3.應(yīng)急處置能力a.針對突發(fā)院感事件的應(yīng)急預(yù)案與演練完善且定期演練/有預(yù)案少演練/無預(yù)案風險等級判定矩陣(示例)可能性后果嚴重性:-------:-----------:-------:-------:-------**輕微****一般****嚴重****致命****高**中風險高風險極高風險極高風險**中**低風險中風險高風險極高風險**低**低風險低風險中風險高風險風險等級定義(示例)*極高風險：感染發(fā)生可能性高且后果嚴重，或雖可能性中等但后果極為嚴重，需立即采取強有力干預(yù)措施，持續(xù)重點監(jiān)控。*高風險：感染發(fā)生可能性較高或后果較嚴重，需制定并實施針對性防控計劃，加強監(jiān)測與改進。*中風險：感染發(fā)生可能性和后果均為中等，或某一方面較高而另一方面較低，需維持常規(guī)防控措施，并關(guān)注薄弱環(huán)節(jié)。*低風險：感染發(fā)生可能性低且后果輕微，保持現(xiàn)有常規(guī)防控措施，定期回顧評估。評估結(jié)論與建議：1.綜合評估風險等級：\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\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