Hoist failure during recovery transfer in an anaesthetised horse: a near miss analysed through a Safety-II lens.

A 660 kg, 11-year-old Irish Sport Horse gelding underwent general anaesthesia for an out-of-hours emergency exploratory laparotomy. After approximately 5 hours of anaesthesia, transfer to the recovery box began, using a ceiling-mounted hoist. As the horse crossed the theatre-recovery interface, the hoist failed due to mechanical disengagement. This resulted in loss of electrical power, leaving the anaesthetised horse suspended approximately 150 cm above the floor for approximately 10 minutes. The horse could not be advanced, reversed, or lowered using standard controls. Activity was paused, and clear roles were allocated; the anaesthesia resident maintained anaesthetic depth and ventilation, while the medicine team prepared the operating table beneath the horse. Continuous physiological monitoring could not be maintained during suspension. Only anaesthetic depth and pulse were assessed, and both remained stable. The operating table was raised to support the horse before the hobbles were cut and the horse was transported to an alternative recovery box. Head and tail rope assistance was used during recovery, which occurred without apparent injury. A no-blame morbidity and mortality review involving clinical facilities and management staff classified the episode as a high-risk near-miss patient safety incident and identified latent system factors. These included a single-point dependency on a powered hoist without a manual override, intermittent pre-event malfunctions, limited formal hoist training, and the out-of-hours context. Organisational responses included maintenance review, simulation training, protocol revision, and a proposal for a hoist upgrade. Safety-II analysis, which examines how adaptive performance creates safety under variable conditions, highlighted how team coordination and organisational learning converted a potential adverse outcome into an opportunity for system improvement.