"For if the trumpet give an uncertain sound, who shall prepare himself to the battle?" (I Corinthians 14:8, KJV).

Frank E. Block, Jr., MD Every clinician is well aware of the problems with audible alarms: False alarms, loud alarms, difficulty determining what is alarming, and inability to quiet an alarm all create distractions that impede patient care. These problems are complicated by the different approaches to alarms among devices. Devices designed by various manufacturers may use different alarm sounds to identify similar events or, alternately, similar sounds may be produced to identify unrelated events. Over several years, the International Organization for Standardization/International Electrotechnical Commission (ISO/IEC) Joint Working Group on Alarms (JWG) developed a standard for audible alarms that suggests the use of melodic tones to identify untoward physiologic changes (IEC 60601-1-8). In this issue of the journal, Wee and Sanderson report a study documenting the challenges in training nursing personnel to use audible alarms that conform to the IEC standard. These authors conclude that “The slow rate of learning and persistent confusions suggest that the IEC 60601-1-8 melodic alarms should be redesigned before they are adopted for clinical practice.” These findings bring the utility of the existing standard into question and, more importantly, challenge us to consider what alarm sounds might actually address the problems with audible alarms. In the 1980s, national standards writing groups began to standardize alarm signals. The British standards group approached Dr. Roy Patterson, a prominent acoustician experienced with alarm design, for assistance. The group told Dr. Patterson that there were “six ways to kill people” (oxygen, ventilation, cardiovascular, temperature/energy delivery, drug infusion, and artificial perfusion). Patterson designed a set of seven prototype alarm sounds, one for each of the six “organ systems” plus a general sound. Each sound had a high-priority form and a medium-priority form that were very similar, but the high-priority version was faster and sounded more urgent. The general alarm also included an optional low-priority alarm sound. When Patterson’s proposed eight alarm sounds were played for various clinicians, the usual reaction was one of astonishment or amusement. To the unknowing ear, they sounded like a set of random electronic noises. Many supposed authorities, including this author, set out to debunk the Patterson sounds, lest they should be adopted by the standards groups and forced upon clinicians worldwide. This author, in opposing the Patterson sounds, suggested that musical alarm sounds might be easier to learn. For instance, the cardiac alarm might be to the tune of “I Left My Heart in San Francisco.” At a dinner at the American Society of Anesthesiologists Annual Meeting in 1990, a learning exercise with possible musical alarm sounds suggested that they could be learned quickly. The United States standards committee accepted the suggestion of melodic alarms and required that medical alarms should use standard musical pitches. The International Standards Committee that wrote the ISO 9703-2 alarm standard in the 1990s abandoned the Patterson sounds and decided upon a 3-note medium priority alarm sound and a 5-note high-priority sound. The musical pitches were not specified, From the Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Accepted for publication October 16, 2007. Conflict of Interest: Dr. Block receives compensation as a consultant to Draeger Medical Systems, Andover, Massachusetts. Address correspondence and reprint requests to Frank E. Block, Jr., MD, 4301 West Markham Street #515, Little Rock, AR 72205. Address e-mail to [email protected]. Copyright © 2008 International Anesthesia Research Society DOI: 10.1213/ane.0b013e3181606927