[1] Ann Arbor VA Med Ctr, Ann Arbor, MI 48105 USA
[2] Univ Michigan Hlth Syst, Dept Med, Ann Arbor, MI 48109 USA
[3] Univ Michigan Hlth Syst, Patient Safety Enhancement Program, Ann Arbor, MI 48109 USA
[4] Univ Michigan Hlth Syst, Div Infect Dis Infect Control & Epidemiol, Ann Arbor, MI 48109 USA