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

Equine anesthesia facilities must ensure hoist redundancy, regular maintenance, and crisis simulation training to prevent catastrophic recovery failures.

This case report describes a critical equipment failure during anesthetic recovery transfer of a 660 kg, 11-year-old Irish Sport Horse gelding following emergency exploratory laparotomy. During hoist-assisted transfer from the operating theater to the recovery box, mechanical disengagement caused complete electrical failure of the ceiling-mounted hoist, leaving the anesthetized horse suspended approximately 150 cm above the floor for roughly 10 minutes. Standard controls were non-functional, preventing advancement, reversal, or lowering of the horse. The clinical team responded by pausing non-essential activity, assigning clear roles, and improvising a solution using the operating table as a platform to support the horse before cutting the hobbles. Continuous physiological monitoring was not maintainable during suspension; only anesthetic depth and pulse were assessed, both remaining stable. Recovery in an alternative box, assisted by head and tail ropes, proceeded without apparent injury. A subsequent no-blame morbidity and mortality review identified multiple latent system failures: sole reliance on a powered hoist without manual override capability, pre-existing intermittent malfunctions, insufficient formal hoist training, and the vulnerability of an out-of-hours context. Institutional responses included maintenance review, simulation-based training, protocol revision, and a hoist upgrade proposal. The case is analyzed through a Safety-II framework, emphasizing that adaptive team performance and organizational learning transformed a high-risk near-miss into a systems improvement opportunity. This report underscores the importance of equipment redundancy, regular maintenance, and structured crisis training in equine anesthesia facilities.

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