Applied Ergonomics 99 (2022) 103609

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Applied Ergonomics
journal homepage: www.elsevier.com/locate/apergo

Discriminating between simultaneous audible alarms is easier with

auditory icons
Judy Reed Edworthy *, Cassie J. Parker, Emily V. Martin
School of Psychology, University of Plymouth, Devon, PL4 8AA, UK

A R T I C L E I N F O A B S T R A C T

Keywords: When more than one audible alarm is heard simultaneously, discrimination may be compromised. This exper­
Clinical alarms iment compares near-simultaneous clinical alarms in two styles, the first are the tonal ‘melodies’ from the 2012/
Audible alarms 2006 version of a global medical device safety standard (IEC 60601-1-8) and the second are the auditory-icon-
Alarm design
style recommended in the 2020 version of the same standard. Sixty-six participants were required to identify the
Auditory cognition
Auditory perception
meaning and priority of four different clinical alarms for one of the two styles of alarm (between-subjects).
Auditory alarms Alarms sounded both singly and in pairs (within-subjects). Results showed that the auditory icon alarms out­
performed the tonal alarms on all measures except one, both for overall accuracy (recognizing both priority and
function) and for partial accuracy (recognizing priority or function but not both). The results add to the growing
body of evidence supporting the use of auditory icon alarms in clinical environments.

1. Introduction
For many years it has been recognized that the audible alarms
associated with the global medical device safety standard IEC 60601-1-8
(IEC 2006; 2012; 2020) are less than optimal. These alarms have been
shown to be difficult to learn (Edworthy et al., 2014, 2017; Sanderson
et al., 2006; Wee and Sanderson, 2008) and exceedingly difficult to
distinguish between when more than one is heard at a time (Lacherez
et al., 2007). More recently, model-checking approaches to the predic­
tion of masking between IEC alarms demonstrates that masking between
alarms sounding simultaneously is also theoretically possible (Bolton
et al. 2018, 2019, 2020a, 2020b Hasanain et al., 2017).
A series of studies have been carried out which have developed and
tested a set of auditory icons in support of the updated version of the
standard, published in 2020 (IEC, 2020). This series of studies demon­
strates that auditory icon alarms outperform the current IEC alarms,
which are tonal in nature, on almost all criteria from learnability
(Edworthy et al., 2014, 2017), localizability (Edworthy et al. 2017,
2018), performance in simulation (McNeer et al., 2018; Bennett et al.,
2019) to tasks requiring visual identification of the source of the prob­
lem (McDougall et al., 2020).
The superior performance of auditory icons can be attributed to a
number of reasons. They are easier to learn because they are metaphors
for the problems that they represent, rather than being abstract in
nature, making it easier for listeners to link the sound and the function
that it represents (Belz et al., 1999; Graham, 1999; Keller and Stevens,
2004; Perry et al., 2007; Petocz et al., 2008; Stephan et al., 2006), and
because they are more varied as a group than a traditional set of tonal
alarms (McDougall et al., 2020; Edworthy et al., 2011). They are easier
to localize because they are harmonically richer than typical alarm
sounds, and are more like real sounds (Edworthy et al., 2017, 2018).
These features make them more likely to function as discernible auditory
objects able to form separate auditory streams and therefore have the
potential to be processed simultaneously, or almost simultaneously
(Bregman, 1990; Carlyon et al., 2003). There a rich and complex liter­
ature on auditory objects and auditory streaming which is central not
just to how alarms are potentially discriminated from one another, but
how all sounds in an environment can be thus discriminated through
interactions and interconnectedness of auditory inputs in terms of
spectral and temporal attributes. One of the key concepts in the auditory
streaming literature is the idea of sounds as auditory objects, with sets of
properties and commonalities that make it possible to group a set of
sound parameters as one or more objects (van Noorden, 1975; Rankin
et al., 2017; Chakrabarty and Elhilali, 2019). What we know about
auditory objects and streaming makes it much more likely that
simultaneously-sounding auditory icons should be easier to identify
individually than simultaneously-sounding tonal alarms. This is because
each of the spectral elements of an auditory icon will show similar

* Corresponding author.
E-mail address: jedworthy@plymouth.ac.uk (J.R. Edworthy).

https://doi.org/10.1016/j.apergo.2021.103609
Received 16 February 2021; Received in revised form 3 September 2021; Accepted 11 October 2021
Available online 23 October 2021
0003-6870/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
J.R. Edworthy et al. Applied Ergonomics 99 (2022) 103609

characteristics and change along with other characteristics in a pre­ Table 1

dictable manner, and will be greatly different from those belonging to a
different icon. The old IEC alarms, on the other hand, because they all
have the same temporal pattern and spectrum, will be harder to separate
into different streams and it should therefore be less easy to form
simultaneous alarms into separate auditory objects.
Lacherez et al.’s finding that simultaneous old-version (tonal) IEC
alarms are almost indistinguishable when heard simultaneously is con­
cerning, as auditory alarms often sound simultaneously in real clinical
environments, rather than in a single, orderly fashion. One of the ex­
pectations of the updated auditory icon alarms is that they will be
identifiable when heard simultaneously, much as the sound of one event
can be discerned from another even when the sounds of those events are
simultaneous. In this paper we compare a subset of the ‘new’ auditory
icon IEC alarms with a subset of the ‘old’ tonal alarms, where alarms are
heard either singly or in pairs. We asked participants to tell us both the
meaning of the alarm and its priority (high or medium).
2. Method
2.1. Experimental design
The experiment was a mixed design. Participants listened to a set of
four high- and four medium-priority ‘old’ IEC 60601-1-8 (2012, 2006)
alarms, or a set of four ‘new’ alarms (IEC, 2020) with ‘alarm style’ as a
between-subjects variable. The four functions associated with the alarms
were Cardiovascular, Ventilation, Oxygenation, and Drug administra­
tion for both styles of alarm (all categories of alarm specified in all
versions of IEC 60601-1-8). The within-subjects variable was ‘single’ or
‘paired’, where participants were required to identify a single alarm, or
two alarms heard together. In the ‘single’ condition they were required
to identify the name and priority of the alarm after hearing one of the
eight alarms played singly. In the ‘paired’ condition participants always
heard one of the four high-priority alarms followed by one of the four
medium-priority alarms (never the same alarm), and were required to
identify the meaning of both alarms.
2.2. Participants
Sixty-six participants (60 female, 6 male, Mage = 20.86, age range:
18–49 years) from the University of Plymouth took part in this study. All
participants were recruited from the University’s Psychology Partici­
pation Pool. Participants were required to have normal or corrected-to-
normal hearing in order to complete the study. Ethical approval was
granted by the University of Plymouth Faculty of Health and Human
Sciences ethics committee.
2.3. Materials
Details of ‘old’ IEC alarms tested.
Function Medium Priority High Priority (repeated x 1)
Cardiovascular ceg ceg-gC
Ventilation caf caf-af
Oxygen Cba Cba-gf
Drug administration Cdg Cdg-Cd
NOTE 1: The characters c, d, e, f, g, a, b, C refer to relative musical pitches and C
is one octave above c.
NOTE 2: A high priority alarm signal is generated with the five pulses shown,
repeated once, for a total of ten pulses.
the longer pulses with slightly longer intervals between the pulses, the
entire stimulus lasting just under 1 s. The tonal patterns of the alarms are
seen in Table 1.
‘New ’IEC alarms: High- and medium-priority alarms for the same
four functions (cardiovascular, ventilation, drug administration,
oxygenation) were tested. According to IEC 60601-1-8 (2020), each
function is indicated by an auditory icon (a sound which acts as a
metaphor for the condition), plus a ‘pointer’ indicating the priority.
Thus the two alarms for each function differ only by pointer. The
auditory icons are described in Table 2. The icons are either real-world
sounds or stylized real-world sounds and each has a complex rhythm and
harmonic structure, very different from one another. They vary from just
under 2 s to nearly 3 s depending on the time taken to complete the
sound, as different sounds necessarily take different amounts of time to
complete. The pointer used is an abstract sound in each case: a 10-pulse
(2 x 5 pulse) high-priority pointer and a 3-pulse medium-priority
pointer. The pointers are similar to the General sound in Table 1, but
much faster (the pulses are 0.05 s in length in the high-priority version)
and are harmonically slightly richer than the old alarms. The alarms are
downloadable here: https://isotc.iso.org/livelink/livelink?func=ll&ob
jId=20885884&objAction=browse&viewType=1. The pointers are
embedded within the icon, and appear at the beginning of those sounds
for both high- and medium-priority alarms.
Stimuli were constructed from the individual alarms indicated in
Tables 1 and 2 into ‘single’ and ‘paired’ alarms. For ‘single’ alarms, the
alarms as indicated above were used in the indicated form. For the
‘paired’ alarms, the high-priority version of the alarm always began first,
followed by a medium-priority alarm after 1.2 s 1.2 s was selected on the
basis of pilot testing which suggested that performance for the old
alarms was at floor level until the separation between the first and
second alarms reached 1.2 s.
Because participants heard only eight different pairings, not all
possible high- and medium-alarm pairings were used. A specific alarm
was never paired with another with the same meaning (for example a
high-priority cardiovascular alarm followed by a medium-priority

The experiments were conducted on a desktop computer with a pair Table 2

of circumaural headphones attached. Listening level was set at a Details of ‘new’ IEC 60601-1-8 alarms tested.
comfortable level of approximately 75 dB(A) for all participants. Category of the source Auditory Icon Auditory Icon description
of the alarm condition metaphor
2.4. Alarms Cardiovascular ‘Lup-dup’; A stylized, square/triangle wave-
heartbeat sound based ’heartbeat’ sound with no
‘Old’ IEC alarms: The high- and medium-priority tonal alarms from discernible frequency. Six pulses
formed from three 2-pulse ’lup-
previous versions of IEC 60601-1-8 (IEC 2006, 2012) for the four dup’ sequences
functions Cardiovascular, Ventilation, Oxygenation, and Drug adminis­ Ventilation A single inhale A 1s inhaling sound (like white
tration were used. The alarms were constructed according to the guid­ followed by an noise), followed by a 0.5s gap,
ance provided in the standard. Each alarm was constructed from a pulse exhale followed by a slow exhale with a
long tail
of sound lasting 0.15 s (high priority) or 0.2 s (medium priority). Each
Oxygenation Irregular, stylized Stylized irregular temporal pattern
pulse consisted of a fundamental frequency as in Table 1, with four dripping/ with some discernible pitch; a two-
additional harmonics which were integer multiples of the fundamental. saturation tone sequence superimposed on the
The high-priority alarm consisted of a 2 x 5 pulse burst in the 3 + 2 six-tone pattern
rhythm specified for these alarms, with the entire stimulus lasting Drug Administration Shaking pill Two 0.8s sequences of a 4-rattle
bottle shaking sound
approximately 3.5 s. The medium-priority alarm consisted of three of

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J.R. Edworthy et al. Applied Ergonomics 99 (2022) 103609

cardiovascular alarm), and the Ventilation medium-priority alarm was Throughout the study, data for the single and paired sounding alarms
not used. The Cardiovascular high-priority alarm was combined with the was collected for both correct/incorrect priority identification and
Oxygenation and Drug administration medium-priority alarms; Venti­ correct/incorrect function identification. After completion, participants
lation high-priority was combined with Oxygenation and Cardiovascu­ were given a debrief and given contact details should they wish to
lar medium-priority alarms; high-priority Drug administration was withdraw their data.
combined with Oxygenation and Cardiovascular medium-priority
alarms; and high-priority Ventilation was combined with medium- 3. Results
priority Oxygenation and Cardiovascular alarms. Figs. 1 and 2 show
the waveforms for the paired alarms for High Priority Cardiovascular For each alarm, it was possible for participants to correctly identify
and Medium priority Drug administration. both the priority and the function of the alarm, or one of these, or neither
(except for the priority only of the paired alarm conditions, which is
discussed later in this section). We first consider completely correct re­
2.5. Procedure
sponses, followed by partially correct responses (either function or pri­
ority, but not both).
Participants were randomly allocated to either the old or new con­
Table 3 shows the means, sds and 95% CIs for all conditions and for
dition and were seated in front of the computer monitor at a comfortable
both completely correct (both function and priority identified correctly)
viewing distance, the headphones having been pre-set to a level of
and partially correct (either function or priority identified correctly, but
approximately 75 dB(A). Instructions for the study were visible on the
not both) responses.
monitor for the participant to read. Participants were told the following:
FOUR ANOVAs were carried out on the data, one two-way ANOVA
‘In this experiment we will measure your ability to accurately identify
on the completely correct responses and three 1-way ANOVAs on the
the priority and the meanings of clinical alarms. First, you are given 10
function-only data and the priority-only correct data (in the latter case
min where you will hear eight different alarms, four of which are high-
for the single alarm conditions only). We selected Analysis of Variance
priority and four of which are the medium-priority versions of those
as an appropriate method of analysis because we were interested not
same alarms. You will hear each alarm three times. After this training,
only in the effects of each of the variables of stimulus style and pairing,
you will hear those same alarms either singly or in pairs, and your task is
but in any possible interaction between the two. The presence of an
to identify the priority (high- or -medium-) and the meaning of the
interaction between the two variables would address the issue of ben­
alarm. The meanings of the alarms will be explained in the following
efits to one or other type of alarm beyond mere superiority in detect­
segment’. After reading the brief and completing their informed consent,
ability and/or learning. Separate one-way ANOVAs were carried out on
participants were instructed to put on their headphones and begin the
single and paired data for function-only because the context in which the
study. Exposure to the sounds was identical for all participants. They
alarms were presented were different for single and paired alarms. In the
heard each of the eight alarms on which they were to be tested three
single alarm condition the selection of priority and function were two
times before proceeding with the experiment proper. They were not
separate tasks, but for the paired alarms a ‘function-only’ correct answer
asked to identify the alarms during this training, but were simply
would be due to a mismatch between function and priority (see Fig. 3).
exposed to each of them, there was no criterion on which the partici­
For example, participants might select ‘Cardiovascular’ for the high
pants’ understanding of or memory for the sounds was judged.
priority alarm whereas that selection was in fact correct for the Medium
Participants allocated to the ‘old’ condition heard the alarms in
Priority alarm, or vice versa. Here, the participant has selected the
Table 1, whereas participants in the ‘new’ condition heard those in
correct function but the wrong priority. The ‘priority-only’ measure is
Table 2. Participants first completed the training phase, and were then
only meaningful for the singly-presented alarms, as participants were
given four practice alarms where they were presented with two single
required to select this separately from function. There is no comparable
and two paired alarms in order to familiarize themselves with the task.
response for the paired stimuli. All data was normally distributed.
In the single alarm trials participants were asked to first select the
Completely correct identification: A two-way alarm style (old, new) x
priority of the alarm (Fig. 3), and then to identify the alarm function
pairing (single, paired) analysis of variance showed that the effect of
(Fig. 4).
alarm style was significant, (F(1, 2108) = 375.78, p < .001, dCohen =
For the paired alarms, participants saw a screen with two response
0.817), with mean accuracy of 0.3 for old alarms (SD= .46, CI = 0.18)
boxes. The first asked the participant to identify the function of the high-
and 0.68 for new alarms (SD= .47, CI = 0.21). Pairing also had a sig­
priority alarm. The high-priority alarm was always heard first and then
nificant effect (F(1, 2108) = 108.49, p < .001, dCohen = 0.20), with
followed by the medium-priority alarm, though participants were not
means of 0.6 for single alarms (SD= .49, CI = 0.22) and 0.39 for paired
told this (Fig. 5)
alarms (SD= .49, CI = 0.20). The interaction effect was not significant F
The test phase consisted of thirty-two trials, which consisted of
(1, 2108) = .46, p = .50. Means for the four conditions can be seen in the
sixteen single alarm trials and sixteen paired alarm trials randomly
first column of Table 3.
presented. Trials occurred every 30 s +/- 10 s, thus the whole study took
Correct priority or function identification only: Participants frequently
approximately 30 min. Participants did not complete any other tasks,
identified either the priority or the function of the alarm correctly, but
such as a secondary task as pilot testing suggested that the alarm task
not both. The following one-way ANOVAs consider these responses,
along was sufficiently demanding for participants.

Fig. 1. Old alarm combination: For 1.2 s the HP alarm sounds alone; before it is finished the MP Drug alarm sounds and ends at around 2.2. Seconds; the Car­
diovascular alarm completes its 10-pulse cycle at around 3.4 s.

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J.R. Edworthy et al. Applied Ergonomics 99 (2022) 103609

Fig. 2. New alarm combination: The HP Cardiovascular auditory icon and pointer begin at 0.0 s; the first iteration of the pointer finishes just before 0.5 s; the second
iteration finishes at 1.1. Seconds; the Cardiovascular icon ends at approximately 1.4 s; the MP pointer begins at 1.2 s and ends at about 1.5 s; the MP icon (Drugs)
begins at around 1.4 s and ends at 2.8 s.

1054) = 48.51, p < .001, dCohen = 0.41). A priority-only correct iden­

Fig. 3. First response screen for the single alarm trials.
tification was not possible in the paired conditions.
Function Identification: Here, we considered responses correct if par­
ticipants identified only the function correctly, necessarily including the
completely correct responses considered above. Data for both old and
new alarms is considered together but we consider the single and the
paired alarm data separately for the reasons stated earlier. A significant
difference was found between the number of correctly identified alarm
functions of single alarms in the old alarm condition (M= .43, SD= .50,
CI = 0.18) and new alarm condition (M= .91, SD= .28, CI = 0.14), (F
(1,1054) = 385.27, p < .001, dCohen = 1.19).
A significant difference was also found for the number of correctly
identified alarm functions of paired alarms in the old alarm condition
(M= .37, SD= .48, CI = 0.20) and new alarm condition (M= .69, SD=
.47, CI = 0.20) (F(1,1054) = 120.66, p < .001, dCohen = 0.68).

Table 3
Means (maximum score = 1), standard deviations (1) and Confidence intervals
(2) for each condition for fully correct answers (both function and priority
identified correctly), function only identified correctly and priority only iden­
tified correctly.
Fig. 4. Second screen for single alarm responses. Fully correct Function only Priority only

Single old 0.41 0.43 0.96

which necessarily include the completely correct responses considered (0.491, 0.172) (0.51, 0.182) (0.191, 0.092)
above. Single new 0.78 0.91 0.84
Priority Identification: Here, participants correctly identified the pri­ (0.411, 0.22) (0.281, 0.142) (0.371, 0.182)
Paired old 0.20 0.37 N/A
ority but not the function of the alarm. A one-way ANOVA for the single
(0.401, 0.152) (0.481, 0.202)
alarm conditions gave a significant difference between the number of Paired new 0.59 0.69 N/A
correctly identified priorities in single old alarms (M= .96, SD= .19, CI (0.491, 0.222) (0.471, 0.202)
= 0.09) versus single new alarms (M= .84, SD= .37, CI = 0.18), (F(1,

Fig. 5. Screen for paired alarm responses.

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J.R. Edworthy et al.
4. Discussion
The results show very clearly, with one exception, that the auditory
icon alarms were identified correctly more frequently than were the old
tonal alarms. This is in line with our expectations. In the simplest terms,
responses to the new alarms were correct in the majority, but for the old
alarms correct responses were in the minority. For the paired alarms
completely correct performance (both function and priority identified
correctly) dropped from just under 80% to just under 60% for the icon
alarms, but started at 40% for the old alarms heard singly to a very low
20% in the paired condition. Thus we can conclude that icon alarms are
more resilient to being heard simultaneously than are the old tonal
alarms. Lacherez et al. (2007) comment that because of the poor per­
formance of the old IEC alarms found in their study, mirrored here,
either directives should be provided about the sequencing of the alarms,
or new alarms more able to promote auditory segregation should be
designed. The auditory icons tested here present one version of those
better designs that are possible. We assume that this can be attributed to
better stimulus segregation although our experiment did not specifically
address this issue.
The superior performance of the icon alarms is also demonstrated in
most of the findings for the more liberal measure of correctness, where
we considered an answer correct if participants identified either the
priority or the function of the alarm, but not both. This is meaningful in
real clinical care as the ability to identify the priority but not the
meaning, or the meaning but not the priority, of an alarm is still a useful
cue to solving the problem. The data again mostly show that correct
responses are in the majority for the icon alarm, but in the minority for
the old tonal alarms. The anomaly is the finding for the priority iden­
tification for the single alarms. This was high for the icon alarm (84%)
but at ceiling level (96%) for the old tonal alarms. Participants were very
good at identifying the priority of the old IEC alarms if they were heard
singly, but they were poor at identifying the meaning as performance
was low for completely correct responses. This does not surprise us as
the difference between a medium and high priority alarm with the old
alarms is the difference between a 10-pulse and a 3-pulse alarm, or
between stimuli lasting either approximately 3.5 s or 1.1. seconds, an
easy discrimination to make. How useful this is in practice, when the
clinician may not know that a 10-pulse signal is a high- and a 3-pulse
signal is a medium -priority (our participants were well aware of this),
is a topic of practical concern.
There are two likely reasons for the finding that the auditory icon
alarms were more easily recognized in this study than the old, tonal IEC
alarms both singly and in pairs. It is well established that the new icon
alarms are much easier to learn than the old alarms (Edworthy et al.
2014, 2017; McNeer et al., 2018; Bennett et al., 2019). The tonal alarms
are very similar to one another, and so it is quite likely that listeners
would find it difficult to segregate one auditory stream from another,
and to be unable to identify whether a pulse belonged to one or other of
the alarms when heard together. For the icon alarms, there is very little
possibility that an auditory stream of, for example, a rattling pill box will
somehow be integrated into a separate auditory stream of a stylized
heartbeat sound, thus rendering the listener unable to separate the
streams. As for the pointers, we believe also by making them short they
are more likely to be successfully segregated as they are completely
embedded at the start of the icons, making it easy to differentiate be­
tween the pointers.
Auditory streaming and auditory object identification is as important
in the wider acoustic environment as it is in any clinical situation such as
the ICU and OR. It is important to be able to discriminate between the
alarms and other sounds in that environment. Because many alarms in
those environments are tonal (beyond those in the standard but devel­
oped by individual manufacturers) then there is the prospect of confu­
sion and inability to identify distinct alarms when tonal alarms sound
simultaneously. There is less concern that alarms of this type will be
confused with other, everyday, sounds that are not alarms. While
5
Applied Ergonomics 99 (2022) 103609
simultaneous auditory icon alarms are likely to be easier to discriminate
between, as we have shown here, there may be concern that these alarms
could become confused with other auditory objects that are not alarms
at all, because the auditory icons are real, or close to real, sounds. One
solution to this is to ‘stylize’ the auditory icons so that they are not
exactly real-world sounds, but are somewhat modified so that they are
digital versions retaining the identity of those sounds. For example, in
the standard itself the ‘Cardiovsacular’ alarm is a stylized square-wave
sound which would not be confused with a real heartbeat sound, but
because it retains many of the features of a heartbeat sound, particularly
the rhythm, then it is unmistakeable. The standard allows manufacturers
to develop their own versions of these auditory icons should they so wish
if any problems of this type develop.
In our experiment all alarms emanated from the same spatial loca­
tion (the speaker attached to the computer), which will be true for
clinical situations where alarms are coming from a central, integrated
panel. They were also presented at the same level. This set of conditions
maximises the difficulty of differentiating between more than one
auditory object at once. In real clinical environments, the sounds may
come from different pieces of equipment, or even from different patient
beds located elsewhere in a ward and we would expect this to improve
identification of individual alarm signals. Other factors such as differ­
ences in level can also help with the differentiation of simultaneously
auditory signals (Andeol et al., 2017; Dehais Andeol et al., 2020; Wan,
2019) and is also worthy of further investigation.
We made some compromises in terms of our study in order to ensure
that the experiment was not too onerous on the participants, who were
exposed to approximately 30 min of regular responses to alarm sounds
even with our rather truncated design. These compromises will have had
impacts on the scope of our findings. One of the compromises was that
we tested only four of the eight alarms presented in the standard; the
second was that in the paired condition we always presented the high
priority alarm first; the third was that we tested only one fixed time
interval between the first and the second alarm (1.2 s).
On the issue of testing only four of the old and new IEC alarms not the
full set of eight, it is important to note that one of the alarms not tested is
the ‘General’ alarm which has been demonstrated to be the most
discriminable of the old alarms, probably because of its octave leap
(Sanderson et al., 2006; Wee and Sanderson, 2008). We did not include
it because the new set of alarms does not have an auditory icon for the
general alarm, it consists only of the pointer. As the comparison between
old and new alarms is fundamentally concerned with the use of tonal
alarms and auditory icons, we felt that including the general alarm
would not be the most informative comparison to have made.
In the paired condition, the high priority alarm was always presented
first. This was a compromise we made on the basis of wanting to keep the
experiment manageable for participants and not wishing to fatigue them
unnecessarily. Had we included this as a further variable it would have
increased the size of the experiment substantially. However, a future
experiment could include this variable relatively easily as a counter­
balancing measure and also as a variable of potential interest. We felt
that presenting the high priority alarm first in a sequence of more than
one alarm is more representative of an intelligent alarm system, which
might to some extent prioritise presentations of alarms this way. Our
participants were not told that the high priority alarm was always pre­
sented first, though they may have worked this out during the experi­
ment. This constraint meant that we could not completely measure
partially-correct paired responses.
We selected the 1.2 s gap between first and second alarm on the basis
of pilot testing, where closer intervals were tested. We did not consider
presenting the alarms completely simultaneously because it is already
known that it is almost impossible to identify more than one of the old
alarms when played simultaneously possibly because it is difficult to tell
which tone belongs to which alarm (Lacherez et al., 2007), an auditory
streaming issue, and because if the old alarms are completely simulta­
neous there is a risk of masking (Bolton et al., 2018, 2020a, 2020b;
J.R. Edworthy et al.
Hasanain et al., 2017; Pereira et al., 2020).We would expect the new
alarms to be more discriminable when played simultaneously because it
is much clearer that two separate auditory objects are being presented,
which are unlikely to fuse into a single stream. Further experimentation
would help to establish how close to simultaneous the new alarms can be
presented and still be discriminated.
In this study we found no interaction between alarm style and
pairing, which is somewhat surprising as the greater probability of the
auditory icons being perceived as individual auditory objects might have
predicted that this would be the case. We suggest that interactions may
appear when a range of time intervals are investigated. The easier
learnability of the icons probably accounts for the superior performance
of the icons overall. However, it is very clear from the results that par­
ticipants found it easier to process one alarm than two, which can be
interpreted from a number of perspectives such as shared processing and
workload (Wickens, 2008), inattentional deafness (Dehais et al., 2014),
working memory constraints (Beaman, 2004; Lacherez et al., 2007).
Again, this should be a topic of future investigation.
All of the old alarms were the same length (approximately 3.5 s for
high priority and 1.1 s for medium priority) whereas the new alarms
varied somewhat in length – or at least the icon part of the alarm varied
between 2 and 3 s. The pointer was a fixed length, either 1.1 s for the
high priority or 0.6 s for the medium priority alarm. Given that per­
formance was worse for the old alarms we do not think that stimulus
length and variation in the length of the auditory icons would had much
overall effect on performance, aside from stimulus length being a very
obvious cue in distinguishing between the old high- and medium-
priority alarms, where performance was at 96%.
We are aware that our study used student participants rather than
clinically-trained staff, and that the task set to participants, which was to
listen out for alarms and to report their meaning, is less complex than
those encountered in a real clinical environment. However, our study is
the first to explore near-simultaneous new IEC alarms (and one of only a
few to explore this same question for the old IEC alarms). Our findings
can be used to develop more complex and realistic experimental para­
digms for the future.
Funding
No funding was received for this work.
Intellectual property
We confirm that we have given due consideration to the protection of
intellectual property associated with this work and that there are no
impediments to publication, including the timing of publication, with
respect to intellectual property. In so doing we confirm that we have
followed the regulations of our institutions concerning intellectual
property.
Research ethics
FORMCHECKBOX We further confirm that any aspect of the work
covered in this manuscript that has involved human patients has been
conducted with the ethical approval of all relevant bodies and that such
approvals are acknowledged within the manuscript.
FORMCHECKBOX IRB approval was obtained (required for studies
and series of 3 or more cases)
Authorship
The International Committee of Medical Journal Editors (ICMJE)
recommends that authorship be based on the following four criteria:
1 Substantial contributions to the conception or design of the work; or
the acquisition, analysis, or interpretation of data for the work; AND
6
Applied Ergonomics 99 (2022) 103609
2 Drafting the work or revising it critically for important intellectual
content; AND
3 Final approval of the version to be published; AND
4 Agreement to be accountable for all aspects of the work in ensuring
that questions related to the accuracy or integrity of any part of the
work are appropriately investigated and resolved.
FORMCHECKBOX All listed authors meet the ICMJE criteria.
We attest that all authors contributed significantly to the creation of this
manuscript, each having fulfilled criteria as established by the ICMJE.
FORMCHECKBOX We confirm that the manuscript has been read and
approved by all named authors.
FORMCHECKBOX We confirm that the order of authors listed in the
manuscript has been approved by all named authors.
Contact with the editorial office
FORMCHECKBOX This author submitted this manuscript using his/
her account in EVISE.
FORMCHECKBOX We understand that this Corresponding Author is
the sole contact for the Editorial process (including EVISE and direct
communications with the office). He/she is responsible for communi­
cating with the other authors about progress, submissions of revisions
and final approval of proofs.
FORMCHECKBOX We confirm that the email address shown below is
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sponding Author’s EVISE account is linked, and has been configured to
accept email from the editorial office of American Journal of Ophthal­
mology Case Reports:
Declaration of competing interest
The authors declare the following financial interests/personal re­
lationships which may be considered as potential competing interests:
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