1. Running head: MEDICAL AND HEALTH-RELATED ERRORS
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Medical and Health-Related Errors:
The Impact of Recordkeeping upon Patient Well-Being
Andrew Sexton
University of Puget Sound

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Introduction
As healthcare technology has rapidly evolved on a global level, the providers’
patient population has grown concurrently. The high volumes of patients who all have
records documenting their healthcare generate a large amount of data. This data is not
immune to human error because it needs to be organized. “US healthcare delivery is in
the midst of a profound transformation which results at least in part, from Federal public
policy efforts to encourage the adoption and use of health information technology”
(Middleton et al., 2013). This research proposal focuses on the following question: Will
the conversion and subsequent standardization of medical recordkeeping practices to
individually managed, electronic platforms reduce medical and health-related errors?
Literature Review
Before Electronic Data Collection
A study conducted by Tufo and Speidel (1971) prior to innovations in electronic
health recordkeeping identified many underlying causes of medical error associated with
improper health recordkeeping. Their findings emphasized that regular review of the
accuracy of medical records allows the viewer to refine the data and reduce the
occurrence of errors. This practice appears to be routine in any situation involving large
amounts of vital and impactful data. Their research evokes the idea that even before the
widespread implementation of electronic recordkeeping technology, there was a large
yearning for standardization in medical data collection and the use of health records to
improve the quality of patient care.
Research conducted by Jao, Helgason, and Zych (2009) examined how hard copy
forms of patient billing produced large amounts of error when compared to computerized

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modalities. They designed and implemented a computerized system to compare with
existing methods of hard data entry associated with patient billing. The physicians in the
study who implemented the computerized recordkeeping system found that the amount of
errors experienced was dramatically reduced. The computerized health billing and
recordkeeping system reduced patient cost and ultimately allowed the physicians to
provide a high quality of patient care. Their findings suggest a direct correlation between
the increased efficiency associated with electronic modalities of health recordkeeping and
improved quality of patient care.
Computerized Medical Recordkeeping
Bowman (2013) examined the impact of electronic health record systems on
information integrity. She posed the true benefits of the standardization of electronic
health recordkeeping against the potential drawbacks. The study proposed that “poor
electronic health record system design and improper use can cause electronic health
related errors that jeopardize the integrity of the information in the electronic health
record, leading to errors that endanger patient safety or decrease the quality of care”
(Bowman, 2013). The findings support the notion that errors related to electronic health
recordkeeping are a direct result of improper data entry. Improper data entry also
accounts for errors among more obsolete forms of hard copy data entry in health
recordkeeping. The study suggested that reducing basic design flaws, improving the ease
of usability, and improving the data capturing process would all lead to improved patient
care associated with the reduced occurrence of errors in electronic health recordkeeping.
A study conducted by Dayan et al. (2013) used the Israeli Defense Forces to
observe the costs related to the quality of patient care received when the primary care

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physician utilized electronic health records. The researchers examined the efficiency and
effectiveness associated with electronic health recordkeeping, and the associated cost
savings. The total population of patients sampled was sourced from specialty clinic
providers for the Israeli Defense Forces. The study established an assessment scale to
quantify the qualitative ratings of patient care. They found that electronic health
recordkeeping increased efficiency, improved the quality of patient care, and decreased
the costs associated with less accurate methods of recordkeeping.
Electronic Health Records Gain Traction
The Canadian Adverse Events Study conducted by Baker et al. (2004) examined
how occurrences of adverse events in hospital settings indicated a need to improve
patient safety. The study outlined adverse events as any situation that resulted in
unintended injury or complication resulting in death or prolonged hospital stay. These
adverse events stemmed from errors in health care management. They randomly selected
sample populations of patients from a number of Canadian hospitals, and screened patient
charts with noted adverse events to identify how they could have been prevented. Their
findings suggest that out of millions of annual hospital stays in Canada, a large portion of
adverse events stemming from improper health care management were potentially
preventable.
Middleton et al. (2013) conducted a study via the American Medical Informatics
Association to examine whether electronic health recordkeeping would enhance patient
safety and quality of care. They developed a set of recommendations pertaining to
specified areas of healthcare practice, where provider end-users were urged to incorporate
electronic health recordkeeping into their practice. A usability assessment was developed

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in order to quantify and accurately gauge the effectiveness and ease of adoption of
electronic health recordkeeping practices within a clinical setting. The results of this
assessment as outlined in the study’s findings elucidate the need for a standardized
electronic system in health recordkeeping that provides functional and efficient use
among end-user providers.
Research conducted by Schoen et al. (2007) examined the reported health care
experiences of adults across seven countries. A pinnacle commonality among participants
from all seven countries was a higher incidence of patient reported error associated with
being under the care of multiple practitioners, or for those being treated for comorbid
conditions. The participants completed surveys regarding their qualitative views toward
healthcare accessibility and efficiency. These results were then posed against quantitative
data sets relating to socioeconomic conditions of the seven different countries. Their
findings present the crucial idea that the standardization of health recordkeeping through
electronic modalities will lead to increased patient quality of care, improved efficacy in
medical practice, and the ability to reduce errors associated with synthesizing data from
multiple sources.
Research by Schwappach (2014) examined patient-reported medical errors among
eleven different countries and identified common risk factors associated with patient-
reported medical errors. An international survey was conducted that factored in differing
foreign health care systems and modeled error-reporting probability. Among the eleven
different sample populations surveyed, regression analyses identified the risk factors
associated with patient-reported medical errors. Poor care coordination stemming from
improper medical recordkeeping practices was the greatest common risk factor for

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patient-reported error. Their findings emphasized the importance of a standardized
system of electronic health recordkeeping on an international scale. They highlighted the
commonalities among multiple countries pertaining to preventable patient-reported
medical errors associated with improper health recordkeeping.
Continued Needfor Standardized Electronic Medical Recordkeeping Practices
Research by Pirkle, Dumont, and Zunzunegui (2012) suggests that a lack of
resources affects the quality of health care assured by medical recordkeeping. They assert
that clinical situations where resources are limited detract from the meticulousness of
medical recordkeeping. Their findings suggest that medical recordkeeping should have a
standardized level of quality control, regardless of the associated operational funds. By
broadening the availability of recent innovations in the field of electronic health
recordkeeping to clinical settings with varying levels of resources, medical recordkeeping
can improve the quality of patient care. This improvement relates to efficiencies that
enhance patient data accuracy and reduce associated practitioner error.
Thompson (2010) examined medical recordkeeping in an occupational health
setting. They emphasized the importance of policy related standards being applied to
clinical practice and how compliance to outlined procedures results in increased quality
of patient care. Their findings display that improved quality of patient care correlates
with proper adherence to policies guiding the use of medical recordkeeping systems.
They explained how government regulation provides a standardized level of
accountability for all end-users of electronic health recordkeeping systems. This study
further advances the view that “a national network of electronic health records is being

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viewed as a way to improve the quality of care, improve patient safety, and lower costs”
(Thompson, 2010).
Hypothesis Development
The overarching hypothesis being tested through this research explores how
improper recordkeeping practices have a positive correlation with medical and health
related errors. Multiple hypotheses will be used to examine how various independent
variables explain more variance in the dependent variable. Multiple variables will be
established in order to test the validity of these hypotheses. The following exogenous,
independent variables are being examined to determine the strength of their correlation
with improper recordkeeping and medical and health related errors: gender, age, race, and
level of education completed. Improper recordkeeping is established as the exogenous,
mediator variable. Medical and health related errors are established as the endogenous,
dependent variable. The hypotheses test whether or not the independent and mediator
variables cause the dependent variable to occur. The observed interaction between the
various independent variables and single mediator variable will determine whether they
are capable of explaining more variance in the dependent variable, as apposed to if they
were acting in a mutually exclusive manner.
The first hypothesis states that survey respondents who identify as being male will
be strongly, positively, and directly correlated with medical and health related errors. The
underlying assumption behind this hypothesis is that there are fewer individuals who
identify as being male that work in the medical recordkeeping field. With a smaller
overall population, the rate of occurrences of medical and health related errors would
increase relative to smaller total population.

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The second hypothesis states that survey respondents between the age of 18 and
35 will be strongly, negatively, and directly correlated with medical and health related
errors. The underlying assumption behind this hypothesis is that younger individuals have
more agile minds that allow them to conduct data entry procedures with less occurrences
of systematic and human error.
The third hypothesis states that survey respondents between the age of 36 and 55
will be strongly, positively, and directly correlated with medical and health related errors.
The underlying assumption behind this hypothesis is that older individuals tend to
commit more human and systematic error in data entry.
The fourth hypothesis states that race will be weakly, positively, and inversely
correlated with medical and health related errors. The underlying assumption behind this
hypothesis is that an individual’s race should not have any impact upon whether or not
they commit human or systematic error associated with medical recordkeeping data entry.
The fifth hypothesis states that individuals who have completed a level of
education equivalent to or lower than a high school diploma will be strongly, positively,
and directly correlated with medical and health related errors. The underlying assumption
behind this hypothesis is that individuals who have not gone to college have spent less
time in an academic setting that requires high attention to detail needed to properly enter
data associated with medical recordkeeping.
The sixth hypothesis states that individuals who have completed an undergraduate
bachelor’s degree or higher level of education will be strongly, negatively, and directly
correlated with medical and health related errors. The underlying assumption behind this
hypothesis is that individuals who have completed higher education have been trained to

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accurately convey their thoughts. This academic training requires the individual to
produce precise and correct data.
Methodology
Sample (Participants)
A crucial component to gathering data for the purpose of this research involves
quantifiably defining recordkeeping. Once recordkeeping practices are quantified, sample
populations will be surveyed to determine whether proper recordkeeping is occurring,
and if so to what degree. The sampling frame will be comprised of a representative
sample of United States adults. The specific independent variables being examined
through the multiple hypotheses require a minimum age of 18 years old. This also relates
to the minimum age requirement for hirable employees in the United States medical
recordkeeping field. The sample population needs to be broad and diverse enough to
encompass a large variety of genders, ages, races, and levels of education completed.
According to www.census.gov (2016), as of April 2016, the total United States
population comprises over 320 million people. For the sake of practical data collection
one percent of this figure, or roughly 3 million individuals will participate in this
experimental research. Aiming for this amount of participants will allow for the data to
be more accurately representative of the demographics outlined by the experiment’s
multiple independent variables. A sample population of this size strengthens the validity
of the data. The sampling procedures used in this experiment will help reduce costs, use
time more efficiently, reduce the associated labor requirements, improve the accuracy of
the data, increase reliability in data collection, and provide test units to be modeled in
future research endeavors.

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In order to solicit potential experiment participants, the survey will be mailed to
every household in America. Nonprobability sampling will be used for the sake of
convenience, and to ensure that the probability of any particular member of the
population being chosen is unknown. This strengthens the credibility of the respondent’s
data. A quota sampling procedure will be employed to ensure that the various subgroups
of the total United States population related to the experiment’s independent variable are
pertinently represented.
Design
The experiment is designed to measure improper recordkeeping practices as a
multi-item construct. There will be three cells in the experiment representing the
following variables: independent exogenous, mediator exogenous, and dependent
endogenous. Six separate regression point displacement analyses will be run examining
how the first and second cells independently influence the level of variance in the third
cell. This type of regression analysis requires a pretest-posttest control group
experimental design in order to produce a single treated group score pertaining to the
independent variable. The regression analyses will examine how the second cell would
mediate the relationship between the first and third cell, thus determining whether the
second cell has a greater mediating effect upon the dependent variable than the
independent variable.
Variables
The first independent variable, gender, will be manipulated by employing three
separate moderating variables: male, female, and non-binary. This attempts to account for
any possible gender that participants may identify with. The second independent variable,

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age, will be manipulated by two moderating variables: the 18 to 35-age bracket, and 36 to
55-age bracket. This accounts for any relevant data relating to age collected from
participants. The third independent variable, race, will be manipulated by six different
moderating variables: white, black or African American, American Indian or Alaska
native, Asian, native Hawaiian or Pacific Islander, and Hispanic. This accounts for any
major racial demographics being examined in the fourth hypothesis. The fourth
independent variable, level of education completed, will be manipulated by two possible
moderating variables: high school equivalent or lower, and undergraduate bachelors
degree or higher. This accounts for the participant’s potential education background.
The dependent variables will be measured using figures associated with the
occurrence of adverse events in medical settings in the United States. This quantitative
data is available via United States government health censuses. The moderator variables
will be measured based upon whether they strengthen or weaken the correlations derived
from the multiple regression analyses. The mediator variable will be measured by
establishing a system to quantify qualitative evaluations of proper recordkeeping
practices. A separate and independent study will be conducted that surveys individuals
within the recordkeeping field who can provide credible qualitative statements that will
translate into valid quantitative data. In order to account for the effects of extraneous
variables and measure their effect upon the experimental outcomes, randomization will
be employed. This involves the random assignment of subjects and treatments to groups
in order to equally distribute the effects of the confounding variables to all conditions.

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Procedure
The experiment will be conducted with the goal of minimizing threats to internal
validity while concurrently maximizing external validity. Internal validity exists to the
extent that an experimental variable is truly responsible for any variance in the dependent
variable (Babin & Zikmund, 2016). A potential threat to internal validity is the history
effect, when some change other than the intended experimental treatment occurs during
the course of the experiment that affects the dependent variable. Another potential threat
to internal validity is the cohort effect, where changes in the dependent variable arise due
to differing historical situations between multiple experimental groups. The maturation
effect is a seemingly unavoidable threat to internal validity because the rate of its’
occurrence decreases with growth and experience. In order to avoid testing effects as a
threat to internal validity, the surveys must be presented to potential participants in a
manner that encourages objective responses. Instrumentation effects as threats to internal
validity can be easily avoided by meticulously composing the survey questions. Sample
attrition will not present itself as a potential threat to internal validity because the data is
recorded upon receipt of the completed survey.
External validity is the accuracy with which experimental results can be
generalized beyond the experimental subjects (Babin & Zikmund, 2016). In order to
maximize external validity, regular manipulation checks will be conducted to ensure that
the manipulation produces differences in the independent variable. Attention filters will
be incorporated into the survey to ensure the respondents are genuinely answering the
questions.

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Discussion
The main purpose of this study is to illuminate how recordkeeping practices have
a critical impact upon patient well being due to medical and health-related errors. A high
quality of patient care should be a universal standard. In order to promote a high quality
of patient care within a clinical setting, the literature suggests that the advent of patient
monitored electronic health records will further reduce medical related errors. The
reduction in errors associated with health recordkeeping practices will reduce the overall
occurrence of adverse events in clinical settings, leading to increased quality of patient
care, and a reduction in practitioner liability. To corporate figureheads and academicians
alike, this study will provide concrete empirical data to support the beneficial and
arguably necessary transition toward individually managed, personal health
recordkeeping.
The proposed experimental research has a few limitations that present themselves
in its’ early conceptual stages. As the proposed research is the first of its’ kind to be
conducted, a large amount generalization needs to occur to transition from broad
questions to specific inquiries. Likewise it is unclear what confounding factors may
present themselves in the form of undesignated and extraneous moderating variables.
There is a potential for false face validity to occur within the bounds of this experiment.
The initial data may appear valid superficially due to unexplored confounding variables.
A specific generalization with the independent gender variable may occur because only
three moderator variables exist.
Future research beyond the initial proposal should encompass a much greater
sample size of the total population of United States adults. The greater the sample size,

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the more valid the data becomes. In future related research an additional mediator
variable should be employed: technological error associated with electronic health
recordkeeping. As the electronic medical recordkeeping industry beings to advance, new
and improved technologies will be associated with operational errors. Research by Audet,
Squires, and Doty (2014) explains that current various electronic health recordkeeping
modalities have emerged during the innovator’s phase of the diffusion curve. This
suggests that health information technology as a larger industry is still in its’ infancy, and
as such has ample time to gravitate toward the standardization of individual personal
health recordkeeping.
Conclusion
The central hypothesis being tested through this research is how improper
recordkeeping practices have a positive correlation with medical and health related errors.
In accordance with the six generated hypotheses, six separate regression point
displacement analyses will be run to test the correlation between improper recordkeeping
and medical and health related errors. The goal of this research is to determine whether
the conversion and subsequent standardization of medical recordkeeping practices to
individually managed, electronic platforms will reduce medical and health-related errors.

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