Background: Anesthesiologists accomplish many tasks rapidly during induction of an anesthetic. Key preparation for induction is needed to maximize patient safety. Given the intense environment of the operating room, preparatory steps may be missed either unintentionally or possibly even intentionally to save time. We conducted this study to determine the incidence of missed steps in the operating room immediately before induction. Methods: In this study, 200 surgical procedures were randomly checked for missed steps before induction of anesthesia using a "Revised Preanesthetic Set-Up." Additionally, multiple other operating room/case variables were recorded to determine whether there was correlation between the missed steps and certain variables such as room case load and regional versus general anesthesia. Results: Twenty-three missed steps were discovered. Manual resuscitation device availability and a working suction set-up were the most frequently missed steps. A higher percentage of missed steps was found in cases in which regional was the planned anesthesia technique, in rooms with higher case loads (≥5 cases scheduled), and in rooms that attending anesthesiologists completed the set-up. Conclusions: Missed steps do occur at a significant and measurable rate. Measures need to be taken to decrease the number of missed steps to improve patient safety.