Enhancement of infection prevention case review process to optimize learning from defects.


Hospitals continue to struggle with preventable healthcare-associated infections. Whereas the focus is generally on proactive prevention processes, performing retrospective case reviews of infections can identify opportunities for quality improvement and maximize learning from defects. This brief article provides practical information for structuring the case review process using readily available health system platforms. Using a structured approach for case reviews can help identify trends and opportunities for improvement.





Published Version (Please cite this version)


Publication Info

Reynolds, Staci S, Christopher Sova, Halie Lozano, Kalpana Bhandari, Bonnie Taylor, Erica Lobaugh-Jin, Charlene Carriker, Sarah S Lewis, et al. (2022). Enhancement of infection prevention case review process to optimize learning from defects. Journal of infection prevention, 23(3). pp. 120–124. 10.1177/17571774211066760 Retrieved from https://hdl.handle.net/10161/26918.

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.



Staci Reynolds

Clinical Professor in the School of Nursing

Dr. Staci Reynolds joined Duke in January 2016.  At DUSON, Dr. Reynolds teaches in the ABSN Program (neuroscience nursing) and DNP program (healthcare quality improvement methods). Previously, she clinically served as a Clinical Nurse Specialist (CNS) at DUH within the neuroscience inpatient units and Infection Prevention and Hospital Epidemiology department. In January 2023, Dr. Reynolds was appointed the Editor-in-Chief of the Journal of Nursing Care Quality.  Before coming to DUSON, she was a neurocritical care nurse and a neuroscience CNS at Indiana University Health Methodist Hospital.

Dr. Reynolds received a baccalaureate degree in nursing science from Indiana University (IU) in Indianapolis, Indiana.  She earned a Master’s degree as a Clinical Nurse Specialist at IU in 2011, and completed her PhD at IU in May 2016.  Dr. Reynolds’ dissertation focused on implementation of clinical practice guidelines, and her current research interests includes evidence-based practice implementation and quality improvement.


Sarah Stamps Lewis

Associate Professor of Medicine

Ibukun Christine Kalu

Associate Professor of Pediatrics

My research focus is on developing methods to prevent infections and improve treatment outcomes in children.

Unless otherwise indicated, scholarly articles published by Duke faculty members are made available here with a CC-BY-NC (Creative Commons Attribution Non-Commercial) license, as enabled by the Duke Open Access Policy. If you wish to use the materials in ways not already permitted under CC-BY-NC, please consult the copyright owner. Other materials are made available here through the author’s grant of a non-exclusive license to make their work openly accessible.