The recent evaluation of pulse oximeter implementation in Malawi by Albert et al is the latest article in Anaesthesia exploring the global effort to ensure universal peri-operative pulse oximeter use [1-3]. Peri-operative pulse oximetry use is a standard embedded within both the 2009 WHO Surgical Safety Checklist and the International Standards for Safe Practice of Anaesthesia 2010, and has been used as a surrogate marker for safe surgery by the Lancet Commission on Global Surgery [4-6].