Causal Codes Organizational
Latent Errors Errors that result from underlying system failures

OEX	External	Organizational failures beyond the control and responsibility of the investigating organization. For blood centers, this could apply to hospital. For transfusion services, this could apply to blood centers or other departments within the hospital.
OP	Protocols/ Procedures	The quality and availability of the protocols with the blood center or transfusion service are too complicated, inaccurate, unrealistic, absent, or poorly presented.
OK	Transfer of Knowledge	Failures resulting from inadequate measures taken to ensure that situational or site-specific knowledge or information is transferred to all new or inexperienced staff.
OM	Management Priorities	Internal management decisions in which safety is relegated to an inferior position when faced with conflicting demands or objectives. This is a conflict between production needs and safety. Example Decisions made about staffing levels.
OC	Culture	A collective approach and its attendant modes to safety and risk rather than the behavior of just one individual. Groups might establish their own modes of function as opposed to following prescribed methods. Example Not paging a manager on the weekend because that was not how the department operated; "it's just not done".