Background Inter-hospital transfer of neonates is increasingly performed by regionalised dedicated transport services. It has been suggested that the risk of adverse events during the transfer episode can be reduced if transfers are performed by dedicated transport teams.

Aim To categorise and quantify adverse events that occur during emergency inter-hospital transfers of neonates when transferred by a regionalised dedicated neonatal transfer service.

Methods Adverse event data was prospectively collected over a 13 month period between September 2009 and October 2010 during each emergency neonatal transfer performed by our service. Adverse events were categorised into clinical and non-clinical events.

Results During the study period, a total of 1289 emergency transfers were undertaken of which adverse event forms were recorded in 560 transfers. In 52% (n=261) of the transfers one or more adverse event was recorded. 179 non-clinical and 152 clinical adverse events were documented with more than one clinical event recorded in a few transfers. Table 1 shows the numbers, percentages and the broad categories of the adverse events.

Conclusion Many of the adverse events are potentially preventable. 60% of non-clinical adverse events relate to a delay in emergency transfers due to various reasons. 50% of clinical adverse events related to ventilation difficulties (either related to inappropriate endo-tracheal tube position or over ventilation). We recommend that an outreach education programme by the regionalised transfer service should target these issues.