>Background: Critical incidents are common during the inter-hospital transfer of sick patients, and infants are an especially vulnerable group. >Aims: To examine the effect of critical incident review on the number of adverse events during inter-hospital transfer of sick infants. >Methods: Critical incidents over an eight year period are reported from a single neonatal transfer service before and after major service changes were made. The changes were instigated as part of ongoing critical incident reviews. >Results: Changes made as a result of critical incident review significantly reduced the number of incidents contributed to by poor preparation, transport equipment or clinical problems, ambulance delays, and ambulance equipment failure. >Conclusions: The continuous process of critical incident reporting and review can reduce the number of adverse events during the transfer of critically ill infants.
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