128OScope of SAPSE review

128O Scope of SAPSE review A SAPSE review must— (a) establish the facts of the serious adverse patient safety event, including any relevant surrounding context; and (b) identify the factors that may have led or contributed to the serious adverse patient safety event, including but not limited to the following— (i) any relevant factors that are external to the health service entities involved in the event; (ii) organisational and management factors relating to the health service entities involved in the event; (iii) working environment factors, including the assignment and performance of tasks, technology used by the health service entities, team management and staffing allocation; (iv) factors relating to the patients to whom health services were provided by the health service entities involved in the event; and (c) identify any remedial measures that may be taken in relation to the serious adverse patient safety event, and any measures to prevent similar events from occurring in future and improve the quality and safety of the health services provided by the health service entities involved in the event. S. 128P inserted by No. 4/2022 s. 5.