1. A nurse manager is conducting a root cause analysis (RCA)

of a medication error that occurred in her unit. She interviews

the staff nurse who administered the wrong drug to the patient

and asks her to explain what happened. The nurse manager is

using which of the following steps of RCA?

a) Identify what happened

b) Identify why it happened

c) Identify how to prevent it from happening again

d) Implement and monitor the solutions

*Answer: a) Identify what happened

Rationale: The first step of RCA is to identify what happened

by collecting data from various sources, such as interviews,

records, observations, etc. The other steps are done after

identifying what happened.*

2. A quality improvement team is implementing a plan-dostudy-act (PDSA) cycle to reduce the incidence of hospitalacquired infections (HAIs) in their facility. They have

developed a protocol for hand hygiene and are testing it in one

ward for a month. They are currently in which phase of the

PDSA cycle?

a) Plan

b) Do

c) Study

d) Act

*Answer: b) Do

Rationale: The do phase of the PDSA cycle involves testing

the proposed change on a small scale and collecting data on

the outcomes. The plan phase involves identifying the

problem, setting goals, and developing a plan for change. The

study phase involves analyzing the data and comparing it with

the baseline and the goals. The act phase involves

implementing the change on a larger scale, standardizing it