2025 John W. Severinghaus Lecture: It’s Not Your Fault—Or Is It? The Cognitive Basis for Errors - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Anesthesiology . 2026 Feb 13;144(5):1063–1070. doi: 10.1097/ALN.0000000000005839 Search in PMC Search in PubMed View in NLM Catalog Add to search 2025 John W. Severinghaus Lecture: It’s Not Your Fault—Or Is It? The Cognitive Basis for Errors Joyce A Wahr Joyce A Wahr , M.D. 1 Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota. Find articles by Joyce A Wahr 1, ✉ Author information Article notes Copyright and License information 1 Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota. ✉ Address correspondence to Dr. Wahr: Department of Anesthesiology, University of Minneapolis. [email protected] ✉ Corresponding author. Received 2025 Oct 30; Accepted 2025 Nov 3; Issue date 2026 May. Copyright © 2026 American Society of Anesthesiologists. All Rights Reserved. PMC Copyright notice PMCID: PMC13089811 PMID: 41838018 Abstract The human brain is a marvel of cognition, assessing and reacting to the world around us with amazing speed and excellent, but not perfect, accuracy. This rapidity and fluidity of cognition comes with notable, inherent flaws that lead to errors, some of which have disastrous results for patients and providers. This article presents key concepts in cognition and demonstrates how errors can arise from the unconscious mind: errors that we cannot predict, cannot prevent, and may not perceive. Fortunately, there are effective barriers and interventions that can be employed to prevent these unconscious errors from reaching and harming a patient. This article presents a basic review of the literature on cognition and the attendant risk for error and offers potential safeguards every physician can employ to guard against these errors. This article will first explore the ways in which our subconscious cognitive processes generate errors that we cannot predict, cannot prevent, and often cannot even perceive. These errors, so clearly beyond our control, clearly cannot be our fault. Experts have shown us, however, that there are numerous interventions and barriers that can either prevent an error from occurring (forcing functions) or can prevent an error from harming a patient. 1 If these interventions are not implemented and a patient is harmed, then that harm is our fault. This brings us to a critical distinction between an error, which is an unintentional failure to complete an action as planned, and a violation, which is a conscious and intentional decision to not implement those plans that experts tell us are necessary for safety. 2 What follows is a very brief and superficial exploration of the enormous body of knowledge about cognitive processes. Two marvelous books on the subject are the foundation of this presentation: James Reason’s Human Error 3 and Daniel Kahneman’s Thinking Fast and Slow . 4 It should be noted that Kahneman’s exceptional partner in the science presented in Thinking Fast and Slow , Amos Tversky, died relatively young and thus neither shared in the book's authorship nor in Kahneman’s Nobel Prize, although Kahneman’s introduction to the book details their “extraordinary fortune [to have had] a shared mind that was superior to our individual minds.” 4 The limits of time and length mean that many of the topics discussed below are presented in broad strokes and in reality are far more complex and nuanced then as presented. The reader is encouraged to explore these books and others like them to further their understanding of our remarkable cognitive processes. Thinking Fast and Slow Most humans know instinctively that we operate in two planes, or, as Kahneman puts it in Thinking Fast and Slow , 4 two systems (table 1 ) as first defined by Stanovich and West. 5 System 1 is the fast, automatic, unconscious, effortless function that allows us to drive an automobile at 70 miles an hour on a busy highway, while our System 2, the conscious, effortful, deliberate part, can work out the safest way to manage that fragile mitral valve patient on the schedule for tomorrow. Our unconscious brain is truly astounding, miraculous, spectacular in its ability to perform complex maneuvers effortlessly and fast. System 1 can do this because, from the moment that we are born—and even earlier, in utero —it continuously and furiously accumulates sounds, smells, sights, and perceptions, so that by the time we are just 3 or 4 yr old, we have already amassed an amazing matrix of associative memories. System 1 has further organized these associative memories into mental models that it uses continuously to identify the current environment, what is happening, and what might need to be done. This happens without our conscious mind being involved—our unconscious brain simply filters the massive volume of incoming data and presents the most likely scenario of what is going on. However, our brains are primarily designed to alert us to danger and to keep us safe. System 1 is built first and foremost for speed, not precision, and for this reason, its very ability is also its vulnerability. Table 1. The Two Systems 4 , 5 System 1 • Fast • Subconscious • Automatic, with no control • Effortless • What you see is all there is • Synthesizes perceptions into existing mental models • Loves coherence and eschews ambiguity • Joyful and confident System 2 • Slow • Conscious • Uses first principles • Effortful • Easily exhausted • Consciously examines unconscious perceptions and makes (?) rational decisions • Tolerates ambiguity and discordance Open in a new tab In a commonly reported psychological study of recall, 3 subjects briefly shown a drawing of a bedroom with an alarm clock on a nightstand accurately identify it as a bedroom, and if pressed, will give the time shown on the clock. However, the clock has no hands. The test subjects’ unconscious mind had no mental model of a clock without hands and therefore added this detail to have reality better fit the stored mental model of “clock.” In essence, our unconscious System 1 presents to our conscious System 2 a perception of reality rather than reality itself. The propensity of our unconscious mind to alter our perception of reality to fit an existing mental model has been recognized by cognitive psychologists for years. In 1881, James Sully (University College London) published a book titled Illusions 6 in which he defined an illusion as an error that “counterfeits immediate, self-evident knowledge,” resulting in false recollections of how events occurred or even presenting recollections of events that never occurred. Freud (of the “Freudian slip”) described how a wrong name or phrase comes to mind, believing that this occurs because the name that comes to mind has a greater emotional weight or that the name that will not come to mind is repressed due to associated unpleasantness. Freud’s writings on these errors began to establish the view that errors were unconsciously determined. 7 William James (1890) compiled a two-volume collection of everyday cognitive failures. 8 He also discussed how new skills move from conscious actions to subconscious ones: “Habit diminishes the conscious attention with which our acts are performed.” 4 , 8 One of his followers, Hugo Munsterberg, returned to Sully’s reports of the unreliability of eyewitnesses, publishing On the Witness Stand , 9 in which he describes actual court cases in which eye-witnesses gave remarkably different reports of events. We can theorize that this is because each eyewitness has a different set of previous experiences and thus receives from their subconscious a slightly different “illusion” of what occurred. Jastrow in 1905 analyzed more than 300 “lapses of consciousness,” 10 which included both slips of action as well as slips of the tongue. Jastrow also was perhaps the first to discuss factors that led to “wishful rather than wise” thinking, a topic that Kahneman and Tversky would explore in depth decades later. A decade after James and Munsterberg, a group of “new Gestalt” psychologists came to prominence with their view of how we experience perceptual phenomena. 3 They posited that perceptual phenomena are not passive, exact renderings of reality but are instead shaped by an innate desire to make the current situation fit a remembered “whole.” What is presented to our conscious mind as “reality” is actually a coherent “story” created by the unconscious mind filtering current sensory input through the lens of our previous experiences. Our unconscious will ignore small irregularities between true reality and the stored mental model to which it is being compared. Finally, Bartlett in 1932 brought forward the concept of “schemata” in which he defined a schema as an “active organization of past reactions or of past experiences.” 11 These schemas are unconscious (“active, without any awareness at all”) and “are masses of organized past experiences,” and the process of linking current experience to these schemata can result in predictable biases in remembering—there is a “tendency to interpret presented material in accordance with the general character of earlier experience.” In essence, our subconscious will alter reality to fit the stored model, and the altered perception is what is presented to our conscious mind. It will add hands to the clock to make the story fit. Figure 1 presents the well known Müller-Lyer illusion. 12 The two lines are the same length, but the outward fins in upper line create an illusion of longer length. Even when your conscious System 2 mind knows that the lines are the same length (because you took a ruler and measured them), you will continue to see the lines as unequal. As Kahneman writes, “You have chosen to believe the measurement, but you cannot prevent System 1 from doing its thing; you cannot decide to see the lines as equal, even when you know they are.” 4 An even more striking example is the so-called Ponzo illusion (fig. 2 ). 13 The figures are the same size, but the lines denoting perspective or distance tell System 1 that the figure on the right should be much smaller than the one on the left because it is farther away; since the retinal images are the same size, the figure on the right must be much larger than the one on the left. Again, a measurement will demonstrate the truth, but System 1 will not allow you to see true reality but only its interpretation of reality. Fig. 1. Open in a new tab Müller-Lyer illusion. Although the horizontal lines are the same length (go ahead, use a ruler to measure them), the addition of inward or outward fins gives the impression of a shorter or longer horizontal line. Fig. 2. Open in a new tab “Ponzo” illusion in which figures that appear to be in the distance seem to be larger than those closest, even though the actual figures are all the same size. (Note that Ponzo never claimed to have discovered this illusion, and it exists in earlier works. However, the web will easily recognize this attribution and provide many similar images). Illustration: J. P. Rathmell. These illusions are not just theoretical concepts but play a vital role in our unconscious errors. Over the past decade or so, there have been multiple case reports in which an anesthesia provider, performing a spinal for an orthopedic procedure or an elective cesarean delivery, has both tranexamic acid (TXA) and bupivacaine on their medication tray. 14 Inadvertently, the provider injects TXA intrathecally, often with severe consequences (fig. 3 ). 15 When providers are caught in a devastating syringe or vial swap like this, they often, bewildered, assert that they did read the label, that they did check the vial. It is entirely possible, given our understanding of “illusions,” of “ignoring minor irregularities,” that they actually DID look at the label—they DID check the ampoule, but System 1, having no stored schema of giving TXA intrathecally, “corrected” the retinal image to fit the stored mental model of performing a spinal anesthetic with bupivacaine and presented to the provider an ampoule or vial that actually appeared to read “bupivacaine.” Fig. 3. Open in a new tab Look-alike ampoules and vials of tranexamic acid (TXA) and bupivacaine. Reprinted with permission from Kaabachi O, Eddhif M, Rais K, Zaabar MA. Inadvertent intrathecal injection of tranexamic acid. Saudi Journal of Anaesthesia 2011; 5:90–2. doi: 10.4103/1658-354X.76504. Copyright 2011 Wolters Kluwer Medknow Publications. https://www.researchgate.net/publication/51203089_Inadvertent_intrathecal_injection_of_tranexamic_acid/fulltext/5ada360ea6fdcc2935884760/Inadvertent-intrathecal-injection-of-tranexamic-acid.pdf . Kahneman and Tversky were also fascinated by how System 1 can influence System 2 decisions and began to explore in depth the theory of “bounded rationality,” which was first proposed by Herbert Simon. 16 As Kahneman writes, he and Tversky first connected over the question of whether people make good statistical decisions. They knew that children as young as 3 or 4 yr old are excellent grammarians and conform to rules of grammar without conscious thought and assumed that humans would also have learned the rules of numbers and statistics. However, early in their work, they found that even professional statisticians were (amazingly) not good intuitive statisticians. 4 As they explored how people make judgments under uncertainty, they realized that “people rely on a limited number of heuristic principles which reduce the complex tasks of assessing probabilities to . . . simpler judgmental operations. . . . [T]hese heuristics are quite useful but sometimes they lead to severe and systematic errors.” 17 Here is an interesting and illustrative example. Test subjects were presented the following problem: “A bat and a ball together cost $1.10. The bat costs $1 more than the ball. What does the ball cost?” The answer that immediately comes to mind is “10 cents.” This answer comes from System 1, blindingly fast and completely unconscious—but wrong. If the bat is $1 more than the ball and the ball is 10 cents, then the bat costs $1.10, and with the ball cost of 10 cents, together they cost $1.20. Your System 2 could have solved this problem simply and correctly, but System 1 got there first. Incredibly fast . . . and wrong. Our System 1 is miraculous, phenomenal, incredible—but it works in part because it reduces complex problems to simpler equations and hearing “costs $1 more than the ball,” simply subtracts $1 from the problem and thus concludes that the ball costs 10 cents. The earlier optical illusions and this simple math problem might seem like cheap parlor tricks—we think, “I would have gotten that ball and bat problem”—and the illusions are just tricks our eyes play on us. However, these “simple” studies are solid scientific evidence that our unconscious System 1 is actually in charge for most of our waking moments. We love to believe that our conscious, rational mind (System 2) is managing what we do, but the reality is that our System 2 is just the relatively weak rider on the enormously powerful elephant that is System 1. It was exploration of how powerfully System 1 influences our “rational,” system 2 decisions that led to the awarding of the Nobel Prize in Economics to Daniel Kahneman in 2002. Kahneman and Tversky were not economists but had explored in depth how people make decisions about financial choices; their conclusions became known as “prospect theory,” a theory of behavioral economics and decision-making. 18 Kahneman and Tversky showed that our “rational” choices are very often heavily influenced by our System 1, i.e. , making choices based on our intuition, heuristics, and biases rather than on a rational weighing of the data at hand. Kahneman and others have identified many other instances when our System 1 subverts our conscious perceptions and decisions—there are far too many of them to cover in brief discourse. We have already touched on the topic of the “availability” heuristic, the fact that our System 1 does not search for the most accurate mental model or schema; rather, it takes the schema that is most accessible, whether through frequent use, most recent appearance, or most emotionally tinged. This article has also discussed how System 1 can “autocorrect” reality to make it more coherent with a stored schema. System 1 also frequently does not register or present to our consciousness current elements that it deems unimportant to the task at hand. Many of you have seen the video (YouTube, Daniel Simons’s “Test of selective attention”) in which two teams of college students, half in white tee shirts, half in black, are passing a ball around. Each team has a ball, white passing to white, black passing to black. The viewer is asked to count the number of passes the white team makes. It is not easy: the white and black teams are moving past and between each other, and you must concentrate to count correctly. The video stops, and the announcer asks what your count was and says that the correct answer is 15 passes. Then the announcer asks, “But did you see the gorilla?” Rewind the video, and sure enough, about eight passes in, another student dressed in a gorilla suit enters from the right, moves into the midst of the two teams, pauses, beats on their chest, and then exits stage left. When people are not expecting the gorilla, they simply do not see it. The gorilla is not in white and does not pass a basketball. Therefore, System 1 simply does not report its presence to the conscious mind. We have also touched on the “what is seen is all there is” or WISIATI. 4 System 1 is not good at identifying what should be present but is not. Rather than telling the conscious mind that “wow, there is an alarm clock, but it doesn’t have any hands,” it simply corrects what is missing; it puts hands on the clock. Perhaps most unfortunate of all, System 1 is very confident of its perceptions. It does not question whether it is missing a critical detail or has misread the vial label. It is sure that what it thinks it saw was all that was really there: “what is seen is all there is” (or WISIATS). 4 Finally, another twist from our System 1 that is germane to us as physicians is the concept of “familiarity is safe” and that familiar items carry greater value. Robert Zajonc demonstrated that “mere exposure” changed one’s views. 19 At the University of Michigan and Michigan State University, where both campuses have a daily student newspaper; for a period of 6 weeks, each daily paper carried a white ad box at the bottom of the front page. In the box was a single word. These words were pseudo-Turkish words and therefore were unknown to the students. Some of the words ( kardiga and saricik ) were present many times; some ( iktitaf ) were there only once or twice. After the 6 weeks, a survey was sent out in which students were asked whether each of the words represented something good or bad. The words that had appeared many times were more likely to be viewed as something “good”; those that appeared infrequently were viewed as meaning something bad. To System 1, familiarity represents safety and thus something of greater value. As Kahneman puts it, “repetition induces cognitive ease and a comforting feeling of familiarity.” This may explain why it takes 17 to 20 yr for a new guideline to be accepted—new and different guidance (patients who are status post–myocardial infarction should be discharged on beta blockers and aspirin) is dissonant and thus unsafe with our known schemata. So it is that we are now 26 yr after the American Society of Anesthesiologists first published guidance that it is safe for patients to drink clear liquids up to 2 h before surgery, 20 and many of our U.S. hospitals still have a policy of “NPO after midnight.” We have now explored how our unconscious mind, our System 1, not only alters how we perceive reality and how it can subtly subvert our seemingly conscious and rational choices. It should be clear by now that these processes can lead to errors in our everyday life. So what are we to do? We cannot and should not try to alter System 1. It is spectacular in what it can accomplish, second by second reporting to our consciousness where we are, what is happening. System 1 is what makes us expert anesthesiologists. System 1 allows us to effortlessly put in a central line, induce a patient, or start CPR when needed. Our stored schemas allow us to do amazing things every day, and we do not want to hobble System 1 or be afraid of it. It is our core and our essence. System 1 allows us on a regular basis to achieve what James Reason calls “heroic recoveries.” 21 So how then can we embrace our phenomenal System 1 and still protect our patients? We have done an excellent job of it in some areas. As Eliot Grigg has explained, the right side of our anesthesia cockpit, our modern anesthesia workstation, is a marvel of “forcing functions”—safeguards that will not allow us to make an error. Compared to anesthesia machines from the 1980s, current workstations have pin indexing, antihypoxia valves, computer-determined fresh gas flows, and piston-driven ventilation rather than hanging bellows. The left side of our cockpit, our anesthesia cart ( i.e. , medication preparation area), is little different than that used by anesthesiologists in the 1980s. When we make medication preparation or administration errors, we are simply told to “try harder,” “read the label,” or “think about what you are doing.” Those admonishments are well meaning but utterly and simply useless. We simply cannot try harder. We certainly cannot force our unconscious mind to try harder because we are not in control of it. System 1 does what it does brilliantly but without possible acceptance of exhortations to try harder. The only part of our brain that can try harder is our conscious, System 2 mind, but, as described earlier, System 2 is effortful and is not where our brain wants to be. Try this exercise: you are on a hike with your 7-year-old who is training for a soccer season and learning multiplication tables. So, as you hike, you snap off questions: “7 × 3,” “8 × 6,” and “9 × 5,” and she shouts back the answers, fast, automatically, effortlessly, and joyously. However, if you suddenly ask her to tell you what is 17 times 23 . . . well, she can do this using first principles (“10 times 23 is 230, and then 7 times 23 is. . . .”), but she will not enjoy it, and she will stop running . System 2 requires effort, there is limited “effort” available at any time, and there are multiple demands for this limited “effort” reserve. Studies done by Baumeister et al. 22 demonstrate that all types of voluntary effort (mental, physical, and emotional) draw from the same reserve of energy. Physical energy requires effort, conscious calculations require effort, and emotional discipline requires effort. When you are already a bit fatigued from a difficult call rotation and have been disciplining yourself to not snap at that irascible surgeon, you simply do not have the effort reserves to have System 2 oversee every single unconscious System 1 action sequence you do in a day. It is simply impossible and unreasonable. Unfortunately, the simplest and cheapest interventions to prevent harm are also the least effective (fig. 4 ). Those interventions that are the most effective, such as forcing functions or computerization and automation, are also the most expensive and the most difficult to implement. We do have ways to make our medication preparation safer. Martin et al. 23 undertook a Failure Mode Effects Analysis and found 68 possible failure modes in 5 basic steps (19 substeps); implementing prefilled syringes eliminates an entire step (6 substeps, 19 failure modes). However, when we ask our hospital administrators for prefilled syringes or other medication safety recommendations, 1 , 24 we are told that there is no money for that. When we learned about the TXA/bupivacaine case reports, we asked our pharmacy to supply TXA only in min-bags, and again, we were told that we do not have the staff to do that or that the hospital does not have the money. Of course our hospital had the money : in that same year, our hospital system purchased two surgical robots, at a cost of $2 million to $3 million each. A service agreement on just one cost $150,000 annually—the cost of another pharmacist to help implement medication safety recommendations. Our hospitals have the money for medication safety; they are simply choosing to spend it elsewhere. Fig. 4. Open in a new tab Institute for Safe Medication Practices (ISMP) hierarchy of effectiveness of risk-reduction strategies. Copyright ISMP (Institute for Safe Medication Practices). Reprinted with permission. One of the reasons our leadership continually gets away with such weak interventions as “try harder” and re-education is that we anesthesiologists are complicit in this. We internally do believe that we are above average (85% of us believe that!) and that we are less likely to make a serious error and more careful than our colleagues. This is, of course, nonsense—all of us perform the vast majority of our daily tasks using System 1, and all of our System 1 actions are equally vulnerable to the errors discussed. If we are to truly keep our patients safe, we must first acknowledge that we are quite average in our risk of making harmful errors and that it is often pure chance that our swap is innocuous (rocuronium for neostigmine) rather than deadly (undiluted dopamine for doxapram). We anesthesiologists have a powerful voice. Nearly half of any hospital'’s revenue comes from the operating rooms, and we are involved in everything that happens in those rooms. We know what needs to be done to improve patient safety—we need to use our powerful voice to demand effective interventions to keep our patients safe. Research Support Support was provided solely from institutional and/or departmental sources. Competing Interests The author declares no competing interests. Abbreviation: TXA tranexamic acid Part of the work presented in this article has been presented at the Anesthesia Patient Safety Foundation Medication Panel, Post-Graduate Assembly in New York, New York, December 2024, and as the John W. Severinghaus Lecture at the Anesthesiology Annual Meeting 2025 in San Antonio, Texas, October 14, 2025. References 1. Eichhorn JH: APSF hosts medication safety conference. APSF Newsletter 2010; 25. Available at: https://www.apsf.org/article/apsf-hosts-medication-safety-conference/ . Accessed February 24, 2026. [ Google Scholar ] 2. Merry A, Wahr J: Medication Safety during Anesthesia and the Perioperative Period. 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Br J Anaesth 2017; 118:32–43. doi:10.1093/bja/aew379 [ DOI ] [ PubMed ] [ Google Scholar ] Articles from Anesthesiology are provided here courtesy of Wolters Kluwer Health ACTIONS View on publisher site PDF (1.3 MB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top