Rapid advances in neonatal medicine have caused a substantial reduction in neonatal mortality, especially in low birth weight babies. However, caring for newborn infants in the neonatal intensive care unit (NICU) exposes them to invasive therapies and therefore to iatrogenic damage. Moreover, NICU is a complex system with an environment of continuous and emergency care prone to error. Iatrogenesis is defined as an unintended harm or suffering arising from any aspect of health care management . The report To Err is Human by the Institute of Medicine revealed the importance of medical errors in terms of patient harm, death and cost in USA .