1. CAKE session no. 4 Silent Deviations

2. Since our previous session … Our previous CAKE session concerned learning and buddy system Our Buddy system development group are now working your suggestions They will be included in our new system

3. Silent Deviations - series CAKE session no. 4 is the first in a series with a focus on silent deviations CAKE session no. 4: What is silent deviations? CAKE session no. 5: How do we handle silent deviations? CAKE session no. 6: What do we do to improve?

4. Objective We will know the term silent deviations We need to know which procedures that are not good enough We will be better to identify silent deviations

5. What is a silent deviation? A silent deviation is a breach of a procedure that has developed into accepted practice Deliberate or not? What characterise procedures we break? Accepted by all or by some?

6. The birth of a silent deviation ”I am very busy – and this procedure is too time consuming” ”This procedure is stupid and wrong – it has no effect on safety” ”This is how I was taught to do it – everybody does it this way” ”This procedure is just too big for the small task I want to do” ”My boss told me to do it this way”

7. Silent deviations and barriers A barrier is established to stop a specific and undesired incident from developing Usually we have several barriers for the same incident Our procedures is one of these barriers If other barriers should fail, all we have left is our procedure In this situation someone better execute the procedure – and execute it right

8. Local examples Suggestion: Procedures we sometimes break Procedures as barriers

9. Work Shop Which silent deviations can we identify in our department? Select 3 silent deviations that may have serious consequences Select 3 silent deviations that may not have serious consequences