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Hand hygiene (HH) is poor in the health care environment representing a major public health concern. HH compliance is poorly studied in anesthesia providers who contribute extensively to nosocomial infection. The rate of HH opportunities and compliance by these providers was studied using embedded, clandestine observers. We aimed to quantify HH behaviors and taxonomize failures.Following intensive training, 5 observers masquerading as nursing staff in an academic center, observed the HH of anesthesia providers over a 4-week period throughout the perioperative period using a World Health Organization tool. HH opportunities and HH failures were recorded and categorized using a qualitative content analysis.Nearly 8,000 HH opportunities were observed. HH opportunities averaged 34 to 41/hour and peaked several times at 54/hour. Aggregate failure rate was 82% with a range of 64% to 93% by provider group.HH was very poor among anesthesia providers. The task density of anesthesia care may conspire with an intrinsic HH failure rate to create great opportunity for horizontal and vertical vectors for nosocomial infection. Our observations have led to aggressive educational and ergonomic interventions at our facility. Given the task density of anesthesia care, and the observed failure rates, novel approaches to HH should be investigated.