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Abstract
<jats:p>The Neonatal Emergency Transport Service (NETS) is a cornerstone of regionalised perinatal care that ensures the safe transfer of neonates from "Spoke" hospitals to Level II "Hub" centres. Despite its widespread presence in Italy, with 56 active centres in 2020, transport remains a high-risk clinical activity. This article examines the clinical risk management and the incidence of adverse events (AEs) during neonatal transport and considers, as example, two real-life cases illustrating technical malfunctions and critical clinical-organizational challenges. The literature highlights a lack of standardised AE reporting; however, recent studies, such as the one conducted in Brescia (2021-2023), indicate that AEs occur in 21.8% of transports. Most events (82%) occur during the stabilisation and return phases and are frequently linked to human error (68%).</jats:p>