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The SAFE Operating Room Course

31 January 2018

Most of us will have surgery at some stage in our lives, and although we may be terrified of the process, at least we know that in the NHS, expert care and facilities are available when we need them, free at the point of delivery. Unfortunately, the same is not true for those living in less well-resourced settings. Surgery and anaesthesia are essential components of universal health care, but in low-income and lower-middle income countries nine out of ten people are unable to access even basic surgical care (1,2).

Safety of surgery is a major concern. A recent study published in the Lancet showed that patients in Africa were twice as likely to die after surgery compared to the global average, even though they were young and fit and not undergoing complex operations (3). In the UK, the risk of anaesthesia for routine elective surgery is similar to the risk taken when boarding a flight, but in countries with less developed systems, the risks are orders of magnitude higher, and have not improved since the 1950’s (4). If surgical services are to be developed, they must be developed safely.

The Association of Anaesthetists of Great Britain and Ireland (AAGBI) has been working in partnership with the Association of Anesthesiologists of Uganda (AAU) to strengthen anaesthesia services in Uganda since 2006. Together, the partnership has supported more than 50 doctors to train in anaesthesia, and developed the ‘Safer Anaesthesia from Education’ (SAFE) Obstetric and Paediatric anaesthesia courses. The UK and Ugandan faculty have worked together to deliver these courses throughout East, Central and Southern Africa. With the support of the World Federation of Societies of Anaesthesiologists (WFSA) and partners, SAFE anaesthesia training has now been delivered to 2825 providers in 26 countries, with 343 completing the ‘train the trainer’ courses.  Funding from the DFID funded Health Partnership Scheme has been central to this success.

Safe surgery and anaesthesia requires trained staff with access to equipment, drugs, electricity, running water and oxygen supplies. Safety also depends on the workforce doing the basics well, such as counting swabs, and giving antibiotics on time, and for the clinicians to work together as a team. We have learned from our single specialty training courses that all members of the team need to be involved if new knowledge is to be embedded in practice. The WHO ‘Safe Surgery Saves Lives’ programme showed that effective communication and teamwork, a focus on routine safety checks, and strict adherence to critical care processes can half the perioperative death rate and major complications after surgery. The important first step is to make sure that all members of the team are aware of this!

With this in mind, the AAGBI/AAU sought out new partners. We identified a motivated team of experts from surgery, anaesthesia, nursing and obstetrics and we developed an innovative new course, the SAFE Operating Room course (‘SAFE OR). The partners for the SAFE OR course include the Royal College of Surgeons of England, the Association for Perioperative Practice, and the Lifebox Foundation, and the original pioneers, the AAGBI, WFSA and the AAU.

The SAFE OR course is a multidisciplinary three-day short course for teams of surgeons, obstetricians, nurses and anaesthetists who usually work together, but rarely train together. It is delivered in small groups using low-tech simulation, discussions and role-play, with a few key lectures. The course focuses on the major ‘killers’ in surgery – anaesthesia emergencies such as loss of airway and high spinal, and surgical emergencies such as sepsis, polytrauma and haemorrhage. We also include sessions on the fundamental principles that underlie modern surgical practice  – leadership and communication, surgical site infection prevention, antibiotic stewardship, the WHO Checklist, and enhanced recovery in a LMIC setting. The course has been piloted at the Black Lion Hospital in Ethiopia, and thanks to the Johnson & Johnson Africa Grants

Programme, will now be piloted with the obstetric and surgical teams in Mbarara Uganda.

Dr Emmanuel Ayebale, Lecturer, Department of Anaesthesia, Makerere University, Kampala Uganda says: “We believe safe surgery and anaesthesia begins with education. Only then will a framework exist, facilitating effective communication between all those involved in the care of surgical patients, leading to the desired change in practice and outcomes. SAFE OR provides a foundation on which this framework can be built”.

A highlight of the ‘SAFE’ courses is the rich discussion that takes place when clinicians from different hospitals and different backgrounds meet and share experiences, and often identify simple low-cost solutions to common problems. We wish we had something as innovative as the SAFE OR course in the NHS!

For further information, please contact Isabeau Walker at isabeau.walker@gosh.nhs.uk



  1. World Health Assembly. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. WHA 68.15. Agenda item 17.1. 26th May 2015. http://apps.who.int/medicinedocs/documents/s21904en/s21904en.pdf
  2. Meara J, Leather A, Hagander L et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015; 386: 569–624
  3. Bainbridge D, Martin J, Cheng D et al. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet 2012; 380: 1075–1081
  4. Biccard B, Madiba T, Kluyts H-L et al. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study. Lancet 2018. Published online January 3, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30001-1
  5. Haynes A, Weiser T, Berry B et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. NEJM 2009; 360:491-499

This post was written by:

Isabeau A Walker, Consultant Anaesthetist, Chair AAGBI/WFSA SAFE Steering Group, Lifebox Trustee - Iain H Wilson, Consultant Anaesthetist, Past President AAGBI, Lifebox Trustee


  • Rebecca
    23 Mar 2021 11:10
    We would be interested in this training in Sierra Leone. I tried to email but email bounced back, is there another contact number I can try?
  • Dr Frankie Dormon
    02 Feb 2018 06:28
    Sounds like just what is needed. Well done Isabeau. I look forward to being able to take the course to Lira in Northern Uganda.

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