Analysis of Court Decisions on Safety Incidents in Neonatal Care Units: A Retrospective Study

Purpose: This study aimed to identify the characteristics of neonatal safety incidents that led to litigation and analyze the contributing factors documented in court decisions, thereby providing foundational data for preventing safety incidents in neonatal care units.Methods: A retrospective document analysis was conducted on 41 independent court cases involving neonatal safety incidents in medical institutions and postpartum care centers between January 2000 and December 2024. Quantitative analysis was performed to examine incident characteristics, and contributing factors were identified from the court decisions.Results: Infections were the most common safety incidents leading to litigation (n=18, 43.9%), followed by asphyxia (n=15, 36.6%), and falls and burns (n=3, 7.3% each). Regarding clinical outcomes, 14 cases (34.1%) resulted in death, 13 (31.7%) in recovery with sequelae, and 11 (26.8%) in permanent disability. A breach of the duty of care was identified in 78.0% of the cases (n=32). Contributing factors included inadequate awareness of infection control and changes in patient conditions, inadequate observation and monitoring, improper feeding and thermoregulation practices, a lack of safe environments and equipment, and limitations in staffing and supervision.Conclusion: These findings highlight the need for infection control education tailored to neonatal characteristics, emergency response training, continuous observation protocols, standardized feeding and thermoregulation procedures, and adequate staff members to prevent neonatal safety incidents. Strengthening the regulatory framework of postpartum care centers is urgently required to reduce preventable harm to neonates.