Circulation 94,429 • Volume 26, No. 3 • Winter 2012   Issue PDF

LIFEBOX: Promoting Patient Safety Around the World

Dr Iain H Wilson; Dr Isabeau Walker; K A Kelly McQueen, MD, MPH; Marcel E. Durieux, PD PhD
Patient safety during anesthesia is a high priority in the western world, but it is an even more urgent issue in developing countries, where anesthesia-related mortality is often appallingly high. So many issues could be addressed in order to improve safety in resource-poor settings that it is hard to know where to begin. The availability of a pulse oximeter in every OR in the world would be a good start—and one program aims to do exactly that. The Lifebox program originated with several anesthesia organizations, and is supported by the WHO. It is described by some of the program initiators in the accompanying article.


LifeboxReports of anesthesia and surgery practice in resource-poor parts of the world commonly include accounts describing shortages of personnel, equipment and drugs, limited access to surgical care, and patients who present late with high severity of disease.1 Not surprisingly, outcomes from anesthesia in these settings are often poor—in some parts of the world, anesthesia-related mortality is 100- to 1000-fold greater than in the USA.2

What can clinicians from the UK and USA do to support our colleagues working under such difficult conditions? Clinicians from the USA have been involved in anesthesia outreach for many years and the ASA recently established the Committee on Global Humanitarian Outreach (GHO) to support the American Society of Anesthesiologists’ vision of improving global anesthesia practice and outcomes. GHO encourages volunteerism, supports anesthesiology education and training in low-income settings, and advocates for long-term partnerships and collaborations between organizations with a common mission.

The World Health Organization (WHO) also has begun to consider the issue of surgery as a public health issue. Around 234 million operations are performed each year and these are associated with 1 million deaths and 7 million serious complications, half of which are likely to be preventable.3 Under the leadership of Atul Gawande, MD, renowned surgeon, writer and public health researcher, the WHO developed the WHO Surgical Safety Checklist to help teams work more effectively together. When piloted in a variety of settings, the checklist resulted in a greater than 30% reduction in mortality and morbidity. Backed by these findings, it is being introduced as a routine measure in many countries.3

One of the requirements of the checklist is that a pulse oximeter be used during surgery. This simple, non-invasive monitor was introduced into practice in the early 1980s; it transformed the ability of anesthesia professionals to monitor their patients and quickly spread to every area of the hospital. Without doubt millions of lives have been saved due to the widespread introduction of pulse oximetry.

For colleagues working in developing countries the situation is very different. Many are working without access to pulse oximeters and are required to monitor their patients with a precordial stethoscope and a finger on the pulse. There are significant price barriers to the introduction of pulse oximeters, and (as is frequently the case in the developing world) difficulties in replacing components such as probes and batteries often lead to a very short lifespan of the device. Recently it has been estimated that at least 70,000 operating rooms do not have a pulse oximeter,4 but the overall need for oximeters in health care is much greater. All areas of the world where resources are in short supply are affected.

Recently Atul Gawande in partnership with the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the World Federation of Societies of Anaesthesiologists (WFSA), and the Harvard School of Public Health formed a new charity, Lifebox (, which aims to promote the use of the WHO Surgical Safety Checklist in developing countries and also to make available a good quality pulse oximeter for use in operating rooms anywhere in the world.

Following a tender by the WFSA, a contract was awarded to Acare Technology Limited Taiwan to supply a pulse oximeter that exceeds the WHO specifications and is particularly suited to the difficult conditions found in low-income settings. This oximeter can be purchased or donated via the Lifebox website and sent to any clinician or non-profit hospital in low- or low-middle income country for only $250. Replacement probes are only $25 and include a universal finger probe (for ages 1 year to adult) and reusable infant wrap-around finger probes. The oximeter is robust, high quality, battery- or mains-powered and has a monitor with an audible tone, waveform and adjustable alarms. (More details are available on the Lifebox website—all enquiries welcome!)

Lifebox works to ensure that pulse oximeters are only delivered to clinicians or hospitals that have completed appropriate screening. Our favored way to distribute pulse oximeters is to work through locally based clinical colleagues who will help us undertake training in the use of pulse oximetry and the WHO Surgical Safety Checklist. Additionally, local clinicians are often able to help with customs clearance and further distribution within the country.
In July 2011 the AAGBI donated 80 pulse oximeters to colleagues working in Uganda, and a team travelled from the UK to deliver the oximeters and provide checklist training at Mbarara University Teaching Hospital. The Lifebox team has been following up the students and oximeters, and we have been delighted to hear about the many critical incidents identified and lives saved with the device. The checklist also is proving useful where it is taken up, but there is more work needed on this, as is the case in our own hospitals!

Lifebox would welcome donations to purchase oximeters and also partnerships in hospitals in countries where oximetry is not used. Our target is to ensure no patient undergoes anesthesia without a pulse oximeter, and no surgery is undertaken without the use of the WHO surgical checklist. This will bring us another step closer to fulfilling the APSF dictum that no patient shall be harmed by anesthesia. Can you help us?

Dr Iain H Wilson
President AAGBI and Lifebox Trustee

Dr Isabeau Walker
AAGBI Executive and Lifebox Trustee

K A Kelly McQueen, MD, MPH
Chair, American Society of Anesthesiologists, Global Humanitarian Outreach

Marcel E. Durieux, PD PhD
American Society of Anesthesiologists, Global Humanitarian Outreach


  1. Hodges SC, Mijumbi, Okello M, McCormick BM, Walker IA, Wilson IH. Anaesthesia in developing countries – defining the problems. Anaesthesia 2007;62:4-11
  2. Walker IA, Wilson IH. Anaesthesia in developing countries – a risk for patients. Lancet 2008;371:968-9
  3. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA. Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9
  4. Funk L, Weiser T, Berry W, Lipsitz S, Merry A, Enright A, Wilson IH, Dziekan G, Gawande AA. Global operating room distribution and pulse oximetry supply: an estimation of essential infrastructural components for surgical care. Lancet 2010;376:1055-61