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Contributors HN and ERM contributed to data interpretation and writing and revising of the manuscript. VK, NR, H-LH, AE, SGM, WEB, and MJP contributed to data interpretation, revising of the manuscript. KR led the research team, including study conception and design, interpretation of data, writing and revising of the manuscript. All authors gave final approval to the submitted manuscript.
Funding This work was funded by the VA National Center for Patient Safety, Field Office 10A4E via the Patient Safety Center of Inquiry grant awarded in 2016 (PI: Karthik Raghunathan).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.