Applying Human Error Identification To Enhance Stroke Care: A Brazilian Experience

Stroke is the second leading cause of death and the third leading cause of combined death and disability worldwide, with a global cost exceeding $721 billion. In Brazil, it is one of the main causes of death, resulting in 11 deaths per hour. Stroke is a medical emergency that requires prompt treatment, as up to 1.9 million neurons can be lost every minute without intervention. Ischemic stroke can be treated with medications and procedures, positively impacting mortality, and disability rates. Chemical thrombolysis should be performed within 4.5 hours of symptom onset, while mechanical thrombectomy may be indicated between 8 to 24 hours if medication fails. Stroke patient care is complex and Human Reliability Analysis techniques, SHERPA, help identify vulnerabilities and improve the care process. Results: Seventeen critical activities were identified and classified during the service. The most frequent errors were A2 (23%) and C4 (14%). The most critical activities occurred in opening the patient's medical record for the incorrect specialty (activity 1.1), making decisions about thrombolysis (activity 7), and the unavailability of technology (activity 10).
Actions: The protocol was updated and redesigned. The training model was restructured and included individual feedback. Signage was also implemented on the patient arrival form and a communication system with the internal regulatory center to ensure differentiated reception in the emergency room for patients with potential for thrombolysis. The application of the method and systemic changes resulted in improvements in service flow and response time in critical tasks (1 to 9). Although the number of patients is still small, in the first half of 2024, 11 patients were treated at the hospital and 10 received care according to the protocol.
Conclusion: HTA and SHERPA structured the prediction of human errors and reorganized activities with ergonomic principles, optimizing the implementation of the stroke protocol in the health service.

Keywords: Stroke protocol, Stroke Care, HTA, SHERPA, Human reliability analysis, Human reliability tools, Patient safety, Safety in healthcare, Human factors in healthcare, Risk assessment.