Critically ill patients may require investigations and procedures that cannot be performed within the intensive care unit, thus necessitating intrahospital transfer. (2-4) The decision to transfer a critically ill patient needs to be carefully balanced between the benefit of the diagnostic or interventional procedure and the risks associated with the transfer. (4) Adverse physiological changes are frequent events during transfer of critically ill patients and can be life-threatening; ventilator-dependent and haemodynamically unstable patients are at particular risk. (1,2,5) Changes associated with environment, changes in equipment such as ventilators, pumps and monitors, downgrading the intensity of care, absence of backup supplies and failure of staff to indentify deteriorations are key issues that require attention and careful planning when transferring patients. (2,4,6-13) Beckmann et al identified 176 reports of 191 incidents relating to intrahospital transfer from 7525 incident reports submitted to the Australian Incident Monitoring Study in Intensive Care (AIMS-ICU) collected between 1993 and 19992. Serious adverse outcomes were identified in 31%, prolonged hospital stay in 4%, physical/psychological injury in 3% and death in 2% of incidents.