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Success Cause Analysis: Learning from What Works to Advance Safety

Why It Matters

Success Cause Analysis uses root cause analysis methodology to understand the factors that contributed to favorable outcomes instead of adverse events.


A patient experienced a rare and life-threatening anesthetic reaction known as malignant hyperthermia while undergoing a procedure in an outpatient clinic located on a hospital complex. From administration of specialized medications to escalation to the hospital code response team, all involved delivered care seamlessly. The patient had a swift recovery and was discharged a few days later. The hospital’s Quality & Safety team recognized the health care teams’ efforts and initiated a “success cause analysis” to identify factors that contributed to the favorable outcome and implement system improvements to ensure that other outpatient clinics would be more likely to experience a similar outcome in a comparable situation. Contributing factors identified included a prominently displayed sign explaining the escalation process (including code response team phone numbers) and regular interprofessional simulated mock in situ code training. Outpatient leaders in partnership with Quality & Safety professionals reviewed and redesigned outpatient clinics to incorporate success factors. Following the restructure, all outpatient staff were oriented to the success, goals, and modifications.

(Note: All events described in this vignette are fictitious. Any resemblance to real events is purely coincidental.)

Over the past three decades, the predominant approach to improving safety in health care has involved studying adverse outcomes to identify system vulnerabilities and correct them. While this approach has been useful, it has limitations. A focus only on unfavorable outcomes may limit innovation and adaptability and undermine worker morale and engagement.

Thus, another approach — labeled Safety-II — emerged, which acknowledges that human adaptability and system attributes often make things go right in complex, unpredictable environments. This approach aims to learn from all events, including successful work practices. Operationalizing Safety-II has been difficult. While teams routinely apply defined procedures such as FMEA (Failure Modes and Effects Analysis) and RCA (Root Cause Analysis) to understand safety failures, few organizations have structured processes to learn why and how favorable outcomes occur and to hardwire these strategies into systems to promote safe outcomes in the future.

Learn More at the IHI Patient Safety Congress

Success Cause Analysis (SCA) deploys root cause analysis methodology but uses it to understand the factors that contributed to a favorable outcome and develop actions plans to advance system change. Table 1 (see below) highlights some SCA considerations for each component of event analysis.

Table 1. Success Cause Analysis (SCA) Considerations

Component of Event Analysis

Success Cause Analysis (SCA) Considerations

Application to vignette

Event SelectionConsider selecting high-risk events that require multiple systems to come together for a favorable outcome and have lessons for organization-wide implementation.Malignant hyperthermia, though uncommon, was deemed to be of major significance according to the Safety Assessment Code Matrix used by the hospital.
Timing & Team MembershipConsider involving RCA team for SCA (especially if the system has a centralized cause analysis process). Local regulations may impact whether those involved in the actual case can participate in the SCA. We encourage participation of health care teams and patients if regulations allow.Like RCAs, the hospital’s risk manager facilitated the SCA and the team that would typically be involved in an RCA was present. Additional trainees and interprofessional staff from other units not involved in the case joined the discussion.
Fact Finding and Flow DiagrammingUsing an RCA fact-finding and flow diagramming structure can help demonstrate that existing evidence-based approaches can also be used during SCAs and improve consistency and identification of factors that contributed to the favorable outcome.Staff were very willing to share facts of the case and provided their insights into why teamwork and clinical actions worked so well, as well as potential opportunities for improvement. Staff constructed a flow diagram and helped identify additional factors that contributed to the outcome.
Development of Causal StatementsPositive causal statements help clearly identify causal/contributing factors.Biannual simulated interprofessional drills prompted teams to practice escalation, review and update protocols, and address equipment needs before an actual event.
Identification of Actions that Contributed to Favorable OutcomeThe focus should be to identify specific actions that can inform tangible solutions. These solutions should be broadly applicable to a variety of areas.Initiate biannual interprofessional simulated code drills. Latent threats identified during the drills must be trended and reported into regular Quality Assurance and Performance Improvement (QAPI) processes.
ImplementationImplementation should target transferable and generalizable solutions. Recognition of teams involved in cases should be considered.Implementation focused on all outpatient areas on the hospital campus.
MeasurementThis will vary by unit/section. Units that adopt key actions can be monitored for safety measure improvement. Team engagement is necessary to ensure that lessons are adapted to the local unit.

Two measures identified:

  • Percent of individuals who participated in a simulated code within 6 months (target = 90%)
  • Percent of improvement opportunities identified during simulations and addressed
FeedbackIt is essential to share SCA feedback broadly to strengthen collaborative behaviors among teams.Clinical leadership recognized teams involved in the case and celebrated the initiation of an SCA. Quality & Safety professionals shared improvement actions and measures at various QAPI meetings.

The SCA looks deeply at the factors that allowed the team to innovate, collaborate, and adapt, and how these factors relate to other routine aspects of work. Individuals trained in RCA methodology conduct SCAs to systematically review a positive outcome and aims to identify specific actions that other units can use to improve performance and outcomes. Even the seemingly heroic actions of an individual or team may be the product of a culture and structure that promoted that behavior.

In part because they are not error focused, SCA discussions may allow the inclusion of more people than the typical RCA and empower more individuals to share their perspectives without fear. Additionally, SCAs complement and balance traditional adverse event review processes and promote a participatory approach to safety. The engagement and involvement of RCA teams in SCAs may promote collegiality amongst risk management professionals and frontline staff.

We have also found that Success Cause Analysis is a useful strategy to mitigate “third victim syndrome” for quality and safety professionals who — by analyzing only errors — can experience stress and may end up viewing their own systems and teams as unsafe. SCAs also makes it easier to involve patients and families in quality and safety processes and make care more truly person-centered. We strongly encourage health care quality and safety professionals to consider SCAs as part of their strategy to promote psychological safety, staff engagement, and system-learning.

Vinita Parkash, MBBS, MPH, is Associate Professor of Pathology, Yale Medical School. Lara Musser, DO, is Deputy Chief Quality Officer at New York City Health + Hospital/Jacobi/North Central Bronx. Mona Krouss, MD, is Assistant Vice President for Value & Safety at NYC Health + Hospitals, Heidi Baer, MD, is Patient Safety Officer at New York City Health + Hospitals/Jacobi/NCB. Komal Bajaj, MD, MS-HPEd, is Chief Quality Officer at NYC Health + Hospitals/Jacobi/NCB. To learn more, join the authors at session A02: “Success Cause Analysis” as a Strategy to Promote Learning and Staff Engagement during the IHI Patient Safety Congress