1. Mental Health Service Line, Veterans Affairs Medical Center , White River Junction, VT 05009, USA
2. Department of Psychiatry and Dartmouth Institute, Geisel School of Medicine, Dartmouth College , Hanover, NH 03755, USA
3. VA National Center for Patient Safety , Ann Arbor, MI 48106, USA
4. Department of Psychiatry, Geisel School of Medicine, Dartmouth College , Hanover, NH 03755, USA