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Contributors ARL: concept, data collection, drafting of manuscript. KEF and KL: concept, data collection, critical revision of manuscript.
Funding Although this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors, it was done with support from the Clement J Zablocki Veterans Affairs Medical Centre.
Competing interests ARL and KL were VA Chief Residents in Quality and Safety during this work, and KEF was a staff physician at the Clement J Zablocki VAMC.
Ethics approval VA IRB.
Provenance and peer review Not commissioned; externally peer reviewed.