A.C. Feldstein and D.H. Smith and N.R. Robertson and C.A. Kovach and S.B. Soumerai and S.R. Simon and D.F. Sittig and D.S. Laferriere and M. KalterAdvances in Patient Safety: From Research to Implementation http://www. ahrq. gov/downloads/pub/advances/vol3/Feldstein. pdf AHRQ Publication(2005)