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Safety Recommendation Details

Safety Recommendation R-14-072
Details
Synopsis: During the time period between May 2013 and March 2014, the National Transportation Safety Board (NTSB) launched investigative teams to five significant accidents on the Metro-North Railroad (Metro-North): (1) the May 17, 2013, derailment and subsequent collision in Bridgeport, Connecticut; (2) the May 28, 2013, employee fatality in West Haven, Connecticut; (3) the July 18, 2013, CSX derailment on Metro-North tracks in The Bronx, New York; (4) the December 1, 2013, derailment in The Bronx, New York; and (5) the March 10, 2014, employee fatality in Manhattan, New York. In combination, these accidents resulted in 6 fatalities, 126 injuries and more than $28 million in damages. The continued safe operation of Metro-North is vital to New York City and the tri-state area of New York, New Jersey, and Connecticut. As the NTSB investigations progressed, it became apparent that several organizational factors issues were involved in the accidents. The November 2013 NTSB investigative hearing on the Bridgeport and West Haven accidents (the NTSB hearing) explored the role of Metro-North and the Federal Railroad Administration (FRA) organizational factors in these accidents. The NTSB was not alone in observing that organizational factors were relevant to the series of Metro-North accidents. Subsequent actions by the FRA, which conducted a focused audit, and the Metropolitan Transportation Authority (MTA), which formed a Blue Ribbon Panel (BRP) to review safety and created an MTA Board Safety Committee to monitor safety, have reinforced the need to examine both the role of Metro-North and FRA organizational factors in relation to these five accidents. This special investigation report discusses all five of the recent Metro-North accidents investigated by the NTSB, examines some of the common elements of these accidents, and addresses the steps that Metro-North, the MTA, and the FRA have taken as a result of these investigations. The report also highlights lessons learned and provides recommendations to Metro-North, MTA, and several other entities to improve railroad safety on Metro-North and elsewhere.
Recommendation: TO THE TO THE AMERICAN COLLEGE OF PHYSICIANS: Enhance initial and ongoing training to ensure that Board-certified physicians in Internal Medicine can successfully identify the risk factors for, evaluate, and effectively treat obstructive sleep apnea among their patients.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA14SS005
Accident Reports:
Report #: SIR-14-04
Accident Date: 4/2/2014
Issue Date: 11/24/2014
Date Closed: 12/4/2017
Addressee(s) and Addressee Status: American College of Physicians (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: American College of Physicians
Date: 12/4/2017
Response: In a December 1, 2014, letter, Dr. Alguire described the wide variety of educational programs concerning OSA that the ACP offers to member and nonmember internal medicine physicians. Many of these programs offer continuing medical education credits, and a number address OSA risk factors, evaluation, and treatment. At the time of Dr. Alguire’s letter, ACP planned to discuss this issue at its annual meetings in 2015 and 2016 and to include OSA in an interactive program, the Annals of Internal Medicine Virtual Patients, scheduled for the second half of 2015. On February 26, 2015, pending completion of these actions, Safety Recommendation R 14-72 was classified “Open—Acceptable Response.” We note from Dr. Alguire’s recent e-mail that these activities occurred as planned. Consequently, Safety Recommendation R-14-72 is classified CLOSED—ACCEPTABLE ACTION.

From: American College of Physicians
To: NTSB
Date: 10/24/2017
Response: -From Patrick C. Alguire, MD, FACP, Senior Vice President Emeritus, Medical Education, American College of Physicians: I can confirm that the activities did take place as described in the original letter to the NTSB and as you have noted below. (in the email of 10/23/2017)

From: NTSB
To: American College of Physicians
Date: 10/23/2017
Response: Email from NTSB Staff to American College of Physicians: In November 2014 we issued recommendation R-14-72 (shown below) to the American College of Physicians asking for a program to enhance your organization’s programs regarding obstructive sleep apnea (OSA). In December 2014 you wrote to us and described the extensive programs that ACP has regarding OSA. In your letter you described several items scheduled for 2015 and 2016, including plans to discuss this issue at your annual meetings both in 2015 and 2016, and plans to include OSA in an interactive program, the Annals of Internal Medicine Virtual Patients, in the second half of 2015. In February 2015 we replied that we were impressed by the ACP program. We asked that you inform us when these pending actions were completed, and we classified R-14-72 OPEN—ACCEPTABLE RESPONSE. We have not heard anything further, and the recommendation remains open. I would like to close this recommendation. Can you confirm that OSA was discussed at the 2015 and 2016 meetings, and that the interactive program has been completed and includes OSA. If you can confirm this, I will be able to close the recommendation.

From: NTSB
To: American College of Physicians
Date: 2/26/2015
Response: We note that the ACP offers a wide variety of educational programs to member and non member internal medicine physicians, that many of these programs offer continuing medical education credits, and that a number of your programs address risk factors for, the evaluation of, and effective treatment of, OSA. We further note that you plan to discuss this issue at your annual meetings both this year and in 2016, and that you plan to include OSA in an interactive program, the Annals of Internal Medicine Virtual Patients, in the second half of 2015. We are pleased that the ACP is committed to addressing this important safety issue through a number of ongoing and future programs. Pending the completion of your planned actions, Safety Recommendation R 14-72 is classified OPEN—ACCEPTABLE RESPONSE.

From: American College of Physicians
To: NTSB
Date: 12/1/2014
Response: -From Patrick C. Alguire, MD, FACP:, Senior Vice President, Medical Education Division: I am responding on behalf of Robert Center, MD, FACP, Chair of the Board of Regents, American College of Physicians (ACP). I will specifically address the NTSB Recommendation R-14-72: Enhance initial and ongoing training to ensure that Board-certified physicians in Internal Medicine can successfully identify the risk factors for, evaluate, and effectively treat obstructive sleep apnea among their patients. The ACP offers educational programs to member and non-member internal medicine physicians. Most programs offer continuing medical education credits and many are associated with the ability to earn maintenance of certification points from the American Board of Internal Medicine. The ACP uses many channels to deliver its educational programs and some products use multiple channels. Our channels of educational delivery include textbooks, journals, video, digital (web-based and native apps), live meetings and conferences, and point-of-care clinical decision support tools. ACP delivers educational content related to sleep apnea using all these channels. Almost all programs include a self-assessment component. I will discuss first what is ongoing and recent and then address future activities. Medical Knowledge Self-Assessment Program (MKSAP) 16 MKSAP is a learning program used by over 60,000 internal medicine physicians. Published every 3 years, it consists of 11 specialty and subspecialty books and 1200 self-assessment questions. Sleep apnea content is presented In the Pulmonary and Critical Care book and has the following sections: Obstructive Sleep Apnea, Pathophysiology, Risk Factors, Clinical Features and Diagnosis, Treatment. The text also covers Central Sleep Apnea Syndromes with the following sections: Classification and Pathophysiology, Risk Factors, Symptoms and Diagnosis, and Treatment. These sections are associated with self assessment questions. MKSAP 16 provides both continuing medical education credit and maintenance of certification points. ACP Principles and Practices of Hospital Medicine ACP produces a comprehensive textbook of hospital medicine. The topic of sleep apnea is reviewed in chapter 242: Metha A, Schulman D Sleep Apnea and Obesity. In ACP Principles and Practices of Hospital Medicine. McKean SC, Ross, JJ, Dressler, DD, Brotman, DJ, Ginsberg JS. pp 2021-230. 2012; McGraw Hill Companies Inc. The chapter reviews the epidemiology, risk factors, diagnosis, and management of sleep apnea. ACP Clinical Guideline ACP develops three different types of clinical recommendations: Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible. ACP has recently published a clinical guideline on sleep apnea: Qaseem A, Dallas P, Owens DK, Starkey M, Holty JC, Shekelle P, et al. Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161:210-220. This guideline is associated with continuing medical education credit. This guideline is also accompanied by patient educational content: Summaries for patients: diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014 Aug 5;161{3):1-28. doi: 10.7326/P14-9025. PubMed PMID: 25089870. The obstructive sleep apnea guideline is also accompanied by a clinical guideline video accessible at: http://www .acponline .org/m u ltimedia/?bclid= 713149900001&bctid=3 708064371001. Annals of Internal Medicine In the Clinic Series The Annals of Internal Medicine is the premier journal of internal medicine. The Annals is made available as a benefit to our 140,000 members and through subscriptions and institutional licenses worldwide. The Annals publishes an ongoing series of articles on common and important ambulatory care topics. Articles within this series are the most frequently read articles in Annals. The most recent publication in this series was devoted to sleep apnea: Balachandran JS, Patel SR. Obstructive Sleep Apnea. Ann Intern Med. 2014;161:1TC5-1. doi:10.7326/0003-4819-161-9-201411040-01005. This content is associated with continuing medical education credit. Annual Internal Medicine Meeting ACP hosts a live annual scientific meeting. The average annual attendance to this topic is approximately 6000. Each year the curriculum includes lectures on sleep apnea. In 2014 the topic title and learning objectives were: Sleep Disorders 1. What are the various sleep disorders and their systemic complications, especially with regard to perioperative management? 2. What are the benefits and pitfalls of home versus in-laboratory testing? 3. Which clinical clues and diagnostic strategies are used to screen for and identify sleep disorders? 4. What are value-based treatment options for sleep disorders (pharmacologic, devices, and surgical)? This content is also made available post-meeting via audio or video formats in order to extend its educational reach. Annual meeting content is associated with continuing medical education credit and maintenance of certification points. Pri-Med ACP Programs The ACP works collaboratively with Pri-Med, a medical education company, to provide live and webbased educational programs for internal medicine and other primary care physicians. ACP has developed this relationship to educate non-ACP members and other primary care providers. Registration for these meetings is free or provided at a very low cost. During the 2014 academic year, sleep apnea was included in 5 national meetings and 5 regional meetings for a total of 10 presentations in 2014. Average attendance at national meetings is 5000 and average attendance at regional meetings is 700. These programs provide continuing medical education credit. ACP Smart Medicine ACP has developed a point-of-care clinical decision support tool, ACP Smart Medicine. The disease oriented modules are organized into 7 patient care categories: Prevention, Screening, Diagnosis, Hospitalization, Consultation, Therapy, Patient Education, and Follow-up. Obstructive Sleep Apnea is one of the 500 modules within this collection. The content can be accessed by smart phone, tablet, or personal computer. This module can be accessed at http://smartmedicine.acponline.org/content.aspx?gbosld=235&resultCiick=3&CiientActionType=SOLR%20Direct%20to%20Content&CiientActionData=obs. ACP Smart Medicine provides point-of-care continuing medical education credit. In the coming year, ACP will update many of the existing programs and initiate new programs on sleep apnea. Medical Knowledge Self-Assessment Program 17 The newest edition of MKSAP 17 will be released in December of 2015 (Part A) and July 2016 (Part B). The Obstructive Sleep Apnea and Central Sleep Apnea topics and their associated self-assessment questions will be completely revised. Annual Internal Medicine Meeting 2015 and 2016 The 2015 program will include the following topic and learning objectives: Multiple Small Feedings of the Mind: Gastroenterology, Substance Use and Abuse, and Sleep Medicine 1. How do various sleep disorders impact cardiovascular health, and does treating the underlying sleep disorder improve cardiovascular outcomes? 2. Which patients with sleep disorders are appropriate for testing at home rather than in a sleep center? 3. What devices are available for home sleep study testing, and are these devices reliable? 4. My patient has obstructive sleep apnea {OSA) and cannot tolerate a CPAP mask: What should I do now? Planning for the 2016 meeting is underway. The Scientific Program Planning Committee has been made aware of the NTSB recommendation and has affirmed is intention in include sleep apnea content in the 2016 and future scientific programs. Annals of Internal Medicine Virtual Patients This is a creative program that consists of online interactive cases that mirror real patient care decisions and their consequences. Each decision node can take the learner down multiple pathways. Sleep apnea will be a topic included in this program to be published in the second half of 2015.