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Background Patient, family, and visitor hand hygiene can prevent health care-associated infections, but little is known about their hand hygiene knowledge, attitudes, and practices. We aimed to assess patient, family, and visitor hand hygiene knowledge, attitudes, and practices at a pediatric and maternity hospital in Vancouver, British Columbia, Canada. Methods Surveys based on the Theoretical Domains Framework were distributed to patients, families, and visitors to provide cross-sectional qualitative and quantitative data. This was supplemented with covert observations by trained medical students to determine patient, family, and visitor hand hygiene rates. Results Of 348 survey respondents, there was a clear preference for hand washing with soap and water over use of alcohol-based hand rub. Beliefs about consequences were the main driver for hand hygiene. Self-reported hand hygiene rates were higher than observed rates. The overall hand hygiene rate was observed to be 10.3% (72/701), with soap and water used for 75% of hand hygiene events. Conclusion There are misconceptions regarding hand hygiene practices and low hand hygiene rates among patients, families, and visitors. Development of interventions to improve hand hygiene should focus on correcting misconceptions and emphasizing consequences of failing to perform hand hygiene in the health care setting.