Establishing the Kidney dIsease in the National guarD (KIND) registry: an opportunity for epidemiological and clinical research in Saudi Arabia.

BACKGROUND: In Saudi Arabia (SA), there has been an alarming increase in the prevalence of chronic kidney diseases (CKD) over the last three decades. Despite being one of the largest countries in the Middle East, renal conditions remain understudied, and there is limited data on their epidemiology and outcomes in SA. OBJECTIVES: To document the experience of establishing a local renal registry assessing the epidemiology of CKD and identifying potential areas for improving the quality and delivery of care for CKD patients. METHODS: This is a multi-center retrospective registry. Potential participants were identified through the ICD-10 codes from five hospitals serving the National Guard affiliates in SA. Patients aged ≥ 18 years treated in any National Guard hospital since 2010 for glomerulonephritis, CKD, or received hemodialysis, peritoneal dialysis, or renal transplant were enrolled. Once enrolled in the registry, patients were followed to the last visit date. RedCap was used to create and host the online registry platform. RESULTS: A total of 2,912 patients were included, and more than half were younger than 60 years old. Two-thirds of the patients were overweight (25%) or obese (37%). Glomerulonephritis was diagnosed in 10% of the patients, and dialysis-dependent and kidney transplant patients accounted for 31.4% and 24.4%, respectively. Hypertension and diabetes mellitus were detected among 52% and 43% of the participants, respectively. Hemodialysis was the most prevalent dialysis method, with patients spending 3.6 ± 0.4 h per session to receive this treatment. One in every five participants had a kidney biopsy taken (21%). Several barriers and facilitators of the success of this registry were identified. CONCLUSIONS: The KIND registry provides much-needed information about CKD in Saudi Arabia and serves as a model for future projects investigating the natural history and progression of the spectrum of renal diseases. Logistic and financial challenges to the sustainability of registries are identified and discussed.

A Simple and Cheap Hospitalization Risk Assessment Tool for Use in Hemodialysis Patients.

OBJECTIVE: To develop a simple, objective, cheap scoring tool incorporating nutritional parameters and other variables to predict hospitalization and mortality among hemodialysis patients - a tool that could be utilized in low resource countries. METHODS: The following variables were scored according to severity into 0, 1, 2 or 3: BMI, functional capacity, HD vintage in years, serum albumin, serum ferritin, and the number of comorbid conditions (diabetes mellitus, hypertension, ischemic heart disease, cerebrovascular disease). This tool was evaluated on our regular hemodialysis patients who were followed up for 24 months (June 2015 till July 2017). In our study population, the maximum score recorded was 12; accordingly, a score of 6 was used to differentiate between a low-risk group (score < 6) or a high-risk group (score ≥6). The 2 groups were compared (using the Chi square test) for possible differences in mortality and hospitalization rates during the follow-up period. RESULTS: One hundred and forty adult hemodialysis patients were monitored over 2 years; 83 were males and 57 females; 59% of the patients had diabetes mellitus. Twenty-nine patients (30.7%) were found to be in the high-risk group and 111 (79.3%) in the low-risk group. The high-risk patients were almost one and a half times more likely to be hospitalized for vascular access issues than the low-risk group (p = 0.056) and 3 times more likely to be hospitalized for non-vascular access issues than the low-risk group (p = 0.0001). The mortality rate in the high-risk group was 3.1 times that in the low-risk group, but this was not statistically significant. CONCLUSION: Using a simple and cheap assessment tool in hemodialysis patients, we have identified patients at high risk for hospitalization rates and mortality. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=490544.

The impact of introducing automated eGFR reporting on uncovering new cases of chronic kidney disease in a University Hospital in Saudi Arabia.

OBJECTIVE: To determine the impact of introducing eGFR automated reporting on uncovering new cases of Chronic Kidney Disease. METHODS: All serum creatinine (SCr) in adult patients attending outpatient clinics over a two-month period were recorded and eGFR estimated. Cases with a SCr within normal limits but were in CKD stage 3 (<60 mL/min) or higher were recorded and their numbers, percentages and mean ages calculated. Stages 1 and 2 were excluded from analysis because urinary albumin and other urinary abnormalities were not checked. RESULTS: A total of 26,422 SCr from different patients were included. The mean SCr was 92.5 ± 130.9 µmol/ and the mean eGFR was 99.8 ± 32.4 mL/min/1.73 m(2). Of all the10,601 males with normal SCr, 0.84% were in CKD stage 3 and in all the 14,695 female, 19.24% were in stage 2 in stage. Of all the 14,695 females with serum creatinine in the normal range, 200 (1.36%) were in CKD stage 3. The patients in stages 2 and 3 were significantly older. CONCLUSION: If our findings are shown to be true for the rest of Saudi Arabia, one could extrapolate that for each 100,000 serum creatinine assayed for males, 840 new cases will be uncovered in CKD stage 3. The corresponding number for females would be 1360 cases.

Advance medical directives: a proposed new approach and terminology from an Islamic perspective.

Advance directives are specific competent consumers' wishes about future medical plans in the event that they become incompetent. Awareness of a patient's autonomy particularly, in relation to their right to refuse or withdraw treatment, a right for the patient to die from natural causes and interest in end of life issues were among the main reasons for developing and legalizing advance medical directives in developed countries. However, in many circumstances cultural and religious aspects are among many factors that can hamper implementation of advance directives. Islam and Muslims in general have a good understanding of death and dying. Islam allows the withholding or withdrawal of treatments in some cases where the intervention is considered futile. However, there is lack of literature and debate about such issues from an Islamic point of view. This article provides the Islamic perspective with regards to advance medical directive with the hope that it will generate more thoughts and evoke further discussion on this important topic.

Analysis of chronic kidney disease patients by targeted next-generation sequencing identifies novel variants in kidney-related genes.

Despite the enormous economic and societal burden of chronic kidney disease (CKD), its pathogenesis remains elusive, impeding specific diagnosis and targeted therapy. Herein, we sought to elucidate the genetic causes of end-stage renal disease (ESRD) and identify genetic variants associated with CKD and related traits in Saudi kidney disease patients. We applied a genetic testing approach using a targeted next-generation sequencing gene panel including 102 genes causative or associated with CKD. A total of 1,098 Saudi participants were recruited for the study, including 534 patients with ESRD and 564 healthy controls. The pre-validated NGS panel was utilized to screen for genetic variants, and then, statistical analysis was conducted to test for associations. The NGS panel revealed 7,225 variants in 102 sequenced genes. Cases had a significantly higher number of confirmed pathogenic variants as classified by the ClinVar database than controls (i.e., individuals with at least one allele of a confirmed pathogenic variant that is associated with CKD; 279 (0.52) vs. 258 (0.45); p-value = 0.03). A total of 13 genetic variants were found to be significantly associated with ESRD in PLCE1, CLCN5, ATP6V1B1, LAMB2, INVS, FRAS1, C5orf42, SLC12A3, COL4A6, SLC3A1, RET, WNK1, and BICC1, including four novel variants that were not previously reported in any other population. Furthermore, studies are necessary to validate these associations in a larger sample size and among individuals of different ethnic groups.

Higher access-associated bacteremia but less hospitalization among Saudi compared with US hemodialysis outpatients.

Comparison of Saudi patients with chronic hemodialysis to an international benchmark was not performed before. We conducted a prospective surveillance study for all end-stage kidney disease patients served by the hemodialysis unit at King Abdulaziz Medical City (KAMC) in Riyadh, SA, between May 2008 and December 2009. US National Healthcare Safety Network (NHSN) definitions were used for comparison. Among 227 patients with adverse events, 55% were women and their age was 60.2 ± 20.2 years. Events recorded included 339 all-cause hospitalizations, 302 outpatient start of intravenous antimicrobials, and 174 access-associated bacteremias. In comparison with NHSN, hospitalization rate per 100 patient-months was lower (8.6 vs. 10.7, p < 0.001), rates of both antimicrobial start (7.6 vs. 3.5, p < 0.001) and access-associated bacteremia (4.4 vs. 1.3, p < 0.001) were higher, and blood cultures were more likely to grow gram-negative rods (47.9% vs. 21.3%, p < 0.001). Similar to NHSN, permanent catheter was associated with highest, while arterio-venous fistula was associated with lowest event rates, irrespective of event type. KAMC had 2-4 times higher rates of access-associated bacteremia and antimicrobial start as well as a higher catheter prevalence (42% vs. 31%). The lower hospitalization may indicate good control of comorbidities at outpatient level or underutilization of inpatient services.

Insomnia in chronic renal patients on dialysis in Saudi Arabia.

BACKGROUND: Studies have shown that insomnia is a common sleep disorder among patients with end-stage renal disease (ESRD). This study aimed to assess the prevalence of insomnia in Saudi patients with ESRD who are on maintenance dialysis. METHODS: This was an observational cross-sectional study carried out over a period of five months in two hemodialysis centers in Saudi Arabia. To assess the prevalence of insomnia, we used the ICSD-2 definition. We also examined the association between insomnia and other sleep disorders, the underlying causes of renal failure, dialysis duration, dialysis shift, and other demographic data. RESULTS: Out of 227 enrolled patients, insomnia was reported by 60.8%. The mean patient age was 55.7 +/- 17.2 years; 53.7% were male and 46.3% were female. Insomnia was significantly associated with female gender, afternoon hemodialysis, Restless Legs Syndrome, high risk for obstructive Sleep Apnea Syndrome and excessive daytime sleepiness (P-values: 0.05, 0.01, < 0.0001, < 0.0001, and < 0.0001, respectively). No significant association was found between insomnia and other variables, including BMI, smoking habits, underlying etiology of renal failure, dialysis duration, association with hemoglobin, ferritin, and phosphorus or dialysis adequacy as measured by the Kt/V index. CONCLUSION: Insomnia is common in dialysis patients and was significantly associated with other sleep disorders. Greater attention needs to be given to the care of dialysis patients with regard to the diagnosis and management of insomnia and associated sleep disorders.

Ways to Overcome Organ Shortage: Increasing Donor Pool by Accepting Suboptimal Kidney Donors.

Many factors affect organ donations worldwide, including religious factors, legislative decisions, economic factors, presence of organ procurement organizations, cultural issues, the presence of commercial transplant, and other unknown factors. The number of patients with end-stage renal disease has increased by 6% worldwide. Even with more transplant procedures, these numbers have not combated the dramatically increased number of patients on wait lists. With regard to potential living donors, around 50% are either blood group or HLA incompatible with the recipient, which then requires patient desensitization or paired kidney donation or a combination of both. Survival rates of kidney donors and the general population are almost the same 35 to 40 years after donation. Although the renal consequences of diabetes after kidney donation are almost the same as that shown in the general population, other risk factors should be considered, such as hypertension, proteinuria, and low glomerular filtration rate, before donation. It is so far unknown whether donors with impaired glucose tolerance can safely donate. With diabetes, what was considered normal blood sugar in 1960 to 1990 is now considered frank diabetes. What was considered normal blood pressure is now considered hypertension. Because individuals with these parameters were accepted as organ donors in the past and have been shown to maintain good health, it is worth considering the safe use of organs from donors with early diabetes and hypertension. Whereas young donors may have not reached the age at which hypertension, diabetes, and other kidney diseases develop, older donors have the lowest likelihood of developing end-stage renal disease after donation. As a general approach, young donors can be accepted if they have high glomerular filtration rate, but young donors from certain ethnic minorities and/or extensive family history of chronic kidney disease and those less than 18 years old should not be considered.

Blood pressure control, lifestyle and disease awareness of Saudi hypertensive patients.

Mortality and morbidity from hypertension have reached epidemic proportion worldwide. It has been estimated that 874 million adults globally have systolic blood pressure (SBP) of 140 mm Hg or higher. A recent study from Saudi Arabia found 15.2% of adult Saudis were hypertensive of whom 57.8% unaware of this diagnosis. We aim to evaluate the lifestyle advices given to Saudi hypertensive patients, their current lifestyle to determine the effects of these factors on their BP control. Nonrandom convenience sampling of Saudi patients followed up in the clinic by cross-sectional questionnaire. Their BP, blood sugar, and other anthropometric data were measured and provided self-filled questionnaire. Of all participants, 148 known hypertensives on treatment were included in the study with a mean age of 45.7 ± 29.0 years. The mean SBP and diastolic BP were 134.7 ± 21.4 and 85.0 ± 18.9 mm Hg, respectively. The overall awareness score was 77.5% with the highest awareness score for "BP can be controlled by proper management" (93.2%) and the lowest score given for "BP is not affected by alcohol consumption" (63.4%). We found significantly lower mean SBP in those with higher awareness in five of the nine awareness areas inquired. We believe that educating hypertensive patients about their diseases and lifestyle advices has a significant impact on disease control and well-being.

Nonimmunologic Factors Affecting Long-Term Outcomes of Deceased-Donor Kidney Transplant.

OBJECTIVES: We investigated the impact of nonimmuno-logic factors on patient and graft survival after deceased-donor kidney transplant. MATERIALS AND METHODS: All deceased-donor kidney transplants performed between January 2004 and December 2015 were included in our analyses. We used the independent t test to calculate significant differences between means above and below medians of various parameters. RESULTS: All study patients (N = 205; 58.7% males) received antithymocyte globulin as induction therapy and standard maintenance therapy. Patients were free from infection, malignancy, and cardiac, liver, and pulmonary system abnormalities. Most patients (89.2%) were recipients of a first graft. Median patient age, weight, and cold ischemia time were 38 years, 65 kg, and 15 hours, respectively. Delayed graft function, diabetes mellitus, and hypertension occurred in 19.1%, 43.4%, and 77.9% of patients, respectively. The 1- and 5-year graft survival rates were 95% and 73.8%. Graft survival was not affected by donor or recipient sex or recipient diabetes or hypertension. However, graft survival was longer in patients who received no graft biopsy (8.2 vs 6.9 y; P = .027) and in those who had diagnosis of calcineurin inhibitor nephrotoxicity versus antibody-mediated rejection after biopsy (8.19 vs 3.66 y; P = .0047). Longer survival was shown with donors who had traumatic death versus cerebro-vascular accident (5.9 vs 5.3 y; P = .029) and donors below the 50th percentile in age (8.23 and 7.14 y; P = .0026) but less with donors who had terminal acute kidney injury (6.97 vs 8.16 y; P = .0062). We found a negative correlation between graft survival and donor age (P = .01) and 1-year serum creatinine (P = .01). CONCLUSIONS: Donor age, cause of brain death, and acute kidney injury affected graft survival in our study cohort but not donor or recipient sex or posttransplant or donor blood pressure.

Alport's syndrome with focal segmental glomerulosclerosis lesion - Pattern to recognize.

The association between Alport's syndrome (AS) and focal segmental glomerulosclerosis (FSGS) in the same patient is complex and rarely reported. We report a case of a 42-year-old male presenting with proteinuria, microscopic hematuria, elevated serum creatinine and hypertension with unremarkable physical examination apart from obesity. The renal biopsy showed well-established FSGS pattern of injury with mild interstitial fibrosis and tubular atrophy, while the electron microscopic examination demonstrated glomerular basement membranes (GBM) changes compatible with AS. AS can be complicated by segmental glomerular scarring, which can mimic primary FSGS, while familial FSGS can result from mutations in collagen IV network of the GBM. This overlap can complicate histopathological interpretation of renal biopsy, which should be accompanied by mutational analysis for accurate diagnosis and proper therapeutic intervention.

Let Us Listen to Patients: Underutilization of Peritoneal Dialysis from Patients' Perspectives.

Despite the fact that many of the medical outcome data of peritoneal dialysis (PD) have been improving over the past few years, PD remains an underutilized modality in many countries worldwide. Most nephrologists in those countries report a high rate of patients' refusal. We conducted this survey-based study to determine the obstacles behind underutilization of PD in Saudi Arabia from patients' perspectives and to understand the reasons for their refusal. Nine-hundred and twenty hemodialysis (HD) patients, who had never been on PD before, participated in this study. Responses obtained from patients indicate that their refusal of PD could be because they had not received proper counseling and education about PD from their treating nephrologists throughout the course of their disease.

Family Satisfaction in Critical Care Units: Does an Open Visiting Hours Policy Have an Impact?

For critically ill patients, the interaction between health care providers and family members is essential in daily decision making. Improving this relationship has a positive impact on satisfaction with the overall care provided to patients and reduces family member symptoms of depression, anxiety, and posttraumatic stress disorder. In this study, we analyzed the impact of visitation policy (open versus restricted) on family satisfaction using the previously well-validated Critical Care Family Satisfaction Survey (CCFSS) questionnaire. METHODS: This is a cross-sectional prospective observational study conducted between November 1, 2009, and January 31, 2010, in 2 critical care units with 2 different visiting policy systems, unit A (open visiting hours) and B (restricted visiting hours), comparing family satisfaction in both units using the CCFSS questionnaire. Responses were grouped in 5 satisfaction constructs, namely, the support construct, which assesses the degree of satisfaction with the support of the intensive care staff as perceived by relatives; the assurance construct, which assesses the degree of satisfaction regarding honest answers being given and the responder's confidence that the patient is receiving the best care possible; the proximity construct, which assesses the degree of satisfaction with the physical and emotional access to the patient; the information construct, which assesses the degree of satisfaction with the adequacy of information given to relatives; and the comfort construct, which assesses satisfaction with physical comfort and amenities. RESULTS: During the study period, 115 questionnaires were distributed in each of the 2 sites. The response rates in units A and B were 92% (106) and 100% (115), respectively. The mean stay time in the intensive care unit was 3.7 days. There were more trauma cases in unit A and more cardiac patients in unit B. There was no significant difference between the 2 units in any of the 5 satisfaction constructs, the support, assurance, proximity, information, and comfort constructs, although there was a nonsignificant trend favoring the unit with the more liberal visit policy regarding amenities (unit A). CONCLUSIONS: We concluded that family satisfaction to care provided in intensive care as measured by the CCFSS questionnaire was not influenced by frequency of visitation among Saudi families. Factors other than open visiting hours may be important to evaluate.

Implications of ICU stay after brain death: the Saudi experience.

OBJECTIVE: The interval from brain death (BD) to organ harvesting is critical to the success of transplantation. We evaluated the time from BD onset to harvesting and analyzed sources of delay. MATERIALS AND METHODS: This retrospective study was conducted from January 1999 to December 2003. Time intervals analyzed to determine the causes of delay were: time of admission to the intensive care unit (ICU), to the report to the Saudi Center for Organ Transplantation (SCOT), to the documentation of BD, to organ retrieval and/or cardiocirculatory cessation without organ retrieval. RESULTS: During the 5-year analysis, 1834 people were reported to the SCOT. Of those, more than 1511 (80%) were reported during their first week of treatment in the ICU, and BD was documented in 1099 (59.9%). The mean interval from ICU admission to organ retrieval or cardiac arrest was 10.3 days and that from admission to the report to the SCOT was 5.6 days. In the consensual group, the mean interval from the documentation of BD until harvesting was 2 days, and that from documentation until cardiocirculatory cessation without organ retrieval in the nonconsensual group was 5 days. All subjects demonstrated a significant decrease in systolic blood pressure and a significant increase in plasma sodium and serum creatinine levels. The body temperature, serum plasma levels of sodium, and kidney function (measured by the serum creatinine level) of potential donors were compared, and patients with hypothermia, hypernatremia, or renal failure had a shorter stay in the ICU. CONCLUSIONS: Fewer than 30% of the patients could be maintained on mechanical support for more than 1 week after the declaration BD. It is crucial that we increase hospital-staff awareness about the importance of organ donation and transplantation, improve the identification of BD candidates, and enable the early reporting and documentation of BD.

Barriers to Peritoneal Dialysis in Saudi Arabia: Nephrologists' Perspectives.

In Saudi Arabia, only 9% of dialysis patients are on peritoneal dialysis (PD), and this has been the case for years. A number of centers around the world have sought to understand the underutilization of PD by asking nephrologists directly. In this study, we aimed to gather information that will answer the question "Why is PD underutilized in Saudi Arabia?" hoping that a roadmap may be developed to overcome the hurdles the study underscores, allowing for more patients to utilize this valuable modality.

Continuous Mandatory Onsite Consultant Intensivists in the ICU: Impacts on Patient Outcomes.

OBJECTIVE: The aim of this study was to compare the impacts on patient outcomes of continuous versus on-demand access to certified consultant intensivists in the intensive care unit (ICU). METHODS: Two general adult ICUs within the same health-care organization were compared in terms of patient outcomes. One unit featured continuous mandatory presence of a consultant intensivist (unit A), whereas the other had continuous access to a consultant intensivist during daytime hours but only on-demand access during the night-time hours (unit B). The data collected from these 2 units over the same 12-month period included sex, age, APACHE II score, disease category (medical, surgical, or traumatic), ICU mortality, and length of stay. A subgroup analysis was undertaken to assess the impact of disease severity, age, sex, and disease category on mortality. RESULTS: When adjusted for disease severity, mortality was significantly lower in unit A with continuous mandatory 24-hour presence of a consultant intensivist compared with unit B with on-demand access to a consultant intensivist after working hours. Old age, female sex, and a higher APACHE II score were associated with poorer outcomes at both sites. The subgroup analysis revealed that the difference in mortality was only significant among medical patients but not among surgical or trauma patients. CONCLUSIONS: An improved survival rate was observed only among medical patients admitted to the ICU with mandatory continuous access to a consultant intensivist, despite the presence of greater disease severity in the population admitted to this unit.

Medical grand rounds in Riyadh, Saudi Arabia: Current attitudes and barriers.

BACKGROUND: Medical grand rounds (MGRs) are considered key educational tools in most academic medical institutions. In this multi-center cross-sectional survey, we tried to determine the current attitudes of local medical practitioners to MGRs, as well as perceived barriers. METHODOLOGY: A total of 120 physicians from the National Guard Hospital, King Fahad Medical City, King Khalid University Hospital and King Faisal Specialist Hospital participated in the survey. The questionnaire consisted of statements on attitudes and perceived barriers against participating in MGRs, as well as participants' levels of agreement. RESULTS: Most participants attend MGRs regularly (94.2%), claiming that it is mandatory (88%). Participants also agreed that MGRs were important tools for continuing medical education (89.2%) and that they provided an opportunity to both present materials and interact with their colleagues in other divisions (86.7% and 81.6%, respectively). The vast majority of respondents agreed that "topic review/update" and "inviting guest speakers" were the two most preferred suggestions for improving MGRs (94.2% and 92.5%, respectively). Major barriers included constraints of time (43.3%) and topics that were not patient-related (40.8%). CONCLUSION: MGRs in the major Tertiary Hospitals in Riyadh are well attended, and the majority of the local practitioners believe in the positive effect of MGRs in delivering quality and up to date medical knowledge. Time and physician-specific issues were identified as major barriers that needed to be addressed in order to maximize participation of medical staff.

Comparison of the tuberculin skin test and Quanti-FERON-TB Gold In-Tube (QFT-G) test for the diagnosis of latent tuberculosis infection in dialysis patients.

Dialysis patients are more likely than the general population to develop active tuberculosis (TB). In these patients, the availability of a highly sensitive and specific test to diagnose latent TB will ensure earlier treatment and decreased progression to active disease. In the current study, the Quanti-FERON-TB Gold In-Tube (QFT-G) test was compared with the tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection (LTBI) among 200 hemodialysis patients and 15 confirmed TB disease cases in a tertiary care center in Saudi Arabia. Among the LTBI cases, 26 (13%) were TST positive, and 65 (32.5%) were positive by the QTF-G test, with an overall agreement between the 2 tests of 75.5% (k=0.34) being observed. Among the confirmed tuberculosis disease cases, none were positive by TST, and 10 (66.7%) were positive by the QTF-G test, resulting in an overall agreement of 33.3% (k=0). A comparison between the TST and the QTF-G test was performed based on the sensitivity, specificity, and area under the curve (AUC) obtained for the tests. The QTF-G test was more sensitive and less specific than the TST in predicting the confirmed TB disease cases. When we tested the correspondence of the AUC values between the 2 diagnostic modalities, the obtained p-value was 0.0003. In conclusion, the AUCs of the examined diagnostic modalities are significantly different in predicting LTBI and tuberculosis.

Physicians' attitudes toward reporting medical errors-an observational study at a general hospital in Saudi Arabia.

OBJECTIVE: : Accurate medical error reporting is crucial for reducing the occurrence of such errors and their adverse consequences. This study aims to investigate the views of physicians about medical error reporting in a tertiary care hospital in Saudi Arabia. METHODS: : This is a cross-sectional self-administrated survey study. All physicians in the hospital were invited to complete an anonymous survey questionnaire addressing demographic details, as well as attitudes, practice, and views on medical error reporting. RESULTS: : One hundred seven physicians completed the questionnaires (66.5% response rate). Mean (SD) age was 39.8 (9.0) years. One-fifth of the respondents worked in the emergency department, and half had a workload of 40 to 59 h/wk. The reason given by 41.1% for not reporting a medical error by a colleague was that "it is not their responsibility." However, the gravity of the outcome of a medical error by a colleague to the patient was thought to be an important incentive for reporting. Of the physicians, 43% agreed that they would conceal the occurrence of a medical error they incurred to "avoid punishment." Nevertheless, most of the respondents held the view that there exists an ethical underpinning for reporting medical errors and that reporting of medical errors serve a valuable purpose. CONCLUSIONS: : The physicians in our study are likely to disclose errors made by a colleague only if the error resulted in a severe damage to the patient, and as such, medical errors go underreported for a variety of reasons. It was felt that assurance of confidentiality and protection from backlash would promote medical error disclosure.