Multitasking – concurrent task management – is a very common yet complicated cognitive activity. Physician anesthesiologists multitask in complex, intermittently high-workload environments. We scan monitors sequentially and decide on and administer medications while monitoring fluid administration in parallel. Tasks may be delayed by competing demands, which then require prospective memory to recall them back to consciousness. When we are taken out of our routines, prospective memory failures become more common. The failure to complete one or several of numerous tasks (e.g., pre-induction heparin SQ, pre-incision antibiotics, etc.) is to be expected. When engaging prospective memory, there can be a delay or “recovery time” as our minds reconstruct previous sequences of events to identify which tasks were delayed.¹  System Safety is an engineering system approach used to anticipate, manage and prevent a wide range of expected task failures.