Effectiveness of room of errors simulation in patient safety education for nursing students preparing for clinical practice: A quasi-experimental study focusing on three regions in South Korea

Effectiveness of room of errors simulation in patient safety education for nursing students preparing for clinical practice: A quasi-experimental study focusing on three regions in South Korea | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of room of errors simulation in patient safety education for nursing students preparing for clinical practice: A quasi-experimental study focusing on three regions in South Korea Sunmi Jeon, Minyoung Kim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8739568/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Patient accidents are an important problem in healthcare, and patient safety education for nurses is essential to prevent such accidents. Room of errors simulation is a low-cost, high-efficiency method used in nursing education that helps students improve their ability to recognize and resolve errors related to patient safety. This study aimed to develop and implement a room of errors simulation for nursing students preparing for clinical practice and to evaluate the effects on students’ patient safety knowledge, attitude, and performance confidence. Methods This was a quasi-experimental study with a non-equivalent control group pretest-posttest design. The participants comprised 66 students from 3 different nursing colleges in South Korea. The collected data included demographic information, patient safety knowledge, patient safety attitude, and patient safety performance confidence. Data was collected in February and March 2024 and was analyzed using SPSS version 24. Results In total, 66 nursing students were included in the analysis. After completing the room of errors simulation, compared to the control group, the experimental group showed significantly improved scores for patient safety knowledge (t = 65.959, p=.000), patient safety attitude (t = 39.477, p=.000), and patient safety performance confidence (t = 9.668, p=.000). Conclusions The room of errors simulation effectively increased patient safety knowledge, patient safety attitude, and patient safety performance confidence in nursing college students preparing for clinical practice. Patient Safety Medical Errors Room of Errors Simulation Training Nursing Students Figures Figure 1 Figure 2 Background Since the Institute of Medicine in the US published a report, titled “To Err is Human: Building a Safer Health System” that stated that patient safety accidents (PSAs) cause 98,000 deaths and over 1,000,000 injuries per year, PSAs have become a major topic of interest in healthcare [ 1 , 2 ]. PSAs are currently the third leading cause of death for patients in hospitals in the US [ 3 ], and as many as 4 in 100 people die from PSAs in some countries [ 4 ]. An analysis of PSAs reported to the Korea Patient Safety Reporting and Learning System between 2016 and 2024 revealed that 41.6% were due to falls, and 38.6% were medication errors [ 5 ]. Thus, PSAs are an especially important problem for nurses, who interact closely with patients [ 6 ]. Frequently, PSAs occur because of mistakes or careless behaviors by nurses. Such behaviors can cause diverse outcomes in patients, from mild problems to death, and also cause economic damages to the hospital or country because of high medical costs [ 7 ]. Therefore, error-free nursing is required based on principles and concepts related to patient safety. Given the importance of PSAs, education on patient safety is essential for nurses [ 8 ]. Simulation is a technique that has recently been favored in nursing education as a conversational learning method that provides participants with the required knowledge, skills, and attitude in a highly realistic virtual environment [ 9 , 10 ]. Types of simulation include virtual reality, augmented reality, high-fidelity, and low-fidelity [ 11 ]. Of these, low-fidelity simulation is preferred, because it is relatively inexpensive, efficient, and does not require expensive equipment or expert skills. Rooms of errors (ROEs) can be run as low-fidelity simulations [ 12 ]. An ROE, a concept developed at the University of Virginia, is a simulation in which patient safety issues are set up in various hospital environments to be resolved by the participants [ 12 ]. ROEs are indirect patient safety simulations in which participants enter an error-filled environment and must identify as many issues or hazards as possible. Examples of errors might include an incorrect patient name band, fall-related risk factors, or errors relating to medication [ 13 ]. ROEs offer valuable hands-on experience in identifying issues and recognizing potential risks to patient safety. As ROEs are based on simple scenarios, and various clinical errors can be set up, they can be implemented easily, even by instructors with minimal experience in developing scenarios and running simulations [ 14 ]. ROE scenarios are constructed based on commonly reported PSAs [ 15 ]. ROE participants can be individuals or teams, but teams are more effective [ 14 , 16 , 17 ]. Participants can be diverse, including nursing students and medical students, as well as nurses, doctors, and hospital staff [ 12 , 18 , 19 ]. In previous studies, participant satisfaction was high, and ROEs were effective at improving situational awareness and patient safety awareness [ 15 ]. ROEs allow students to integrate their knowledge and experience, by participating in the process of identifying and fixing their own errors [ 14 ]. ROEs also stimulate students’ interest and increase participation in practice, suggesting that they are an efficient form of patient safety education [ 14 ]. The objectives of patient safety education for nursing students are to acquire patient safety competencies and to learn and practice the concept and principles of patient safety [ 20 , 21 ]. The importance of patient safety education is increasingly being recognized by nursing colleges, creating a need for research into effective teaching methods and learning strategies [ 22 ]. As such, this study aimed to develop ROE simulations for students at three different nursing colleges preparing for clinical practice and to investigate the effects of the ROE simulations on students’ patient safety knowledge, attitudes, and performance confidence. Aim of the study The purpose of this study was to investigate the effects of ROE simulations on the patient safety knowledge, patient safety attitude, and patient safety performance confidence of nursing college students preparing for clinical practice. Research Hypothesis Hypothesis 1 The group that participated in the ROE simulation (experimental group) will show improved patient safety knowledge compared to the control group. Hypothesis 2 The group that participated in the ROE simulation (experimental group) will show an improved patient safety attitude compared to the control group. Hypothesis 3 The group that participated in the ROE simulation (experimental group) will show improved patient safety performance confidence compared to the control group. Methods Study design This was a quasi-experimental study with a non-equivalent control group pretest-posttest design, with the objective of testing the effects of ROE simulation on patient safety knowledge, patient safety attitude, and patient safety performance confidence in nursing college students (Fig. 1 ). Participants and setting This study’s participants were third-year students in nursing colleges, preparing for clinical practice. We used convenience sampling to recruit students from three regions with similar curricula. To prevent contamination effects, we recruited control group participants from a nursing college in another city via the department homepage. The specific inclusion criteria were: 1) third-year nursing college students who had completed a classroom practical course; 2) having no experience of ROE simulation education; 3) having no experience of clinical practice. To calculate the number of participants, with reference to previous studies [ 23 ], we used G*power 3.1 with an effect size = 0.8, power (1-β) = 0.9, and confidence level=.05. To account for a dropout rate of 25.0%, we recruited 72 participants, with 36 participants in each group. Study sample All 36 persons in the experimental group participated in the posttest immediately after the intervention (dropout rate, 0.0%). Of the 36 persons in the control group, 6 did not participate in the posttest (dropout rate, 16.7%). Thus, data from 66 persons in total (experimental group: 36 persons, control group: 30 persons) was used in the final analysis (Fig. 2 ). Interventions and procedures Development of the ROE simulation For the ROE simulation, we developed a scenario with errors related to patient safety and named it the “Go Out! Room of Errors” The scenario entailed checking for errors during the hospitalization of a 77-year-old male patient diagnosed with hypertension and diabetes. The medical records provided in advance were progress records, hospitalization records, doctor’s orders, and nursing records. Based on previous studies [ 12 , 13 ], patient safety-related errors were divided into 6 categories: physical injury errors, surrounding environment errors, medication errors, patient identification errors, medical waste management errors, and prescription confirmation errors. There were 23 errors in total across these categories (Table 1 ). Table 1 Errors staged in the room of errors Category Staged safety errors Physical injury errors A needle and alcohol swab were in the bed. The urine bag was being dragged on the floor while the patient had a Foley catheter inserted. A Foley catheter was wrapped around the bedside rail. The bedside rail was not raised. The bed wheels were not locked. There was no sign indicating high fall risk for patients aged 65 or older. Water was spilled on the floor around the bed (wet floor for a high fall risk patient). Surrounding environment errors The patient was not wearing their hospital clothes properly (incorrect trouser length). The bedsheets were soiled with the patient’s urine. There was cigarettes and alcohol on the bedside table. Electronic devices (such as electric kettle and heated mats) were being used. The hand sanitizer dispenser was empty. Medication errors Both RBC blood pack and fluid bag drips were attached (duplicate medication). The patient’s blood type and the transfusion blood type did not match. The fluids were past their use-by date. Patient identification errors The patient’s name did not match the name on the patient chart. High fall risk was not indicated on the patient’s ID bracelet. Medical waste management errors A needle was discarded in the general waste box. Bloodstained gloves and gauze were discarded in the regular waste basket. The ward’s waste basket was overflowing. Prescription confirmation errors The dose of O2 being provided did not match the prescription. The medication being administered did not match the prescription. An AST-positive antibiotic (positive drug response test) was prescribed. Pretest The pretest was conducted between February 1 and February 11, 2024. The participants first completed a consent form and then the pretest questionnaire, which took approximately 10 to 15 minutes. Intervention The ROE simulation was run on March 7, 2024, less than 4 weeks after the pretest. The experimental group was divided into 9 teams of 4 students each for the intervention, and the intervention took around 45 minutes per team. During a 10-minute orientation, the investigators explained the plans for the intervention, precautions during the ROE simulation, and the methods for finding and reporting errors. Thereafter, the participants were given 15 minutes to enter the ROE, find errors related to patient safety, and complete the reporting form. Team members were allowed to discuss with one another, and one research assistant was situated in the ROE to provide instructions. Finally, there was a 20-minute debriefing. Posttest The posttest for the experimental group was performed immediately after the intervention, led by a research assistant. For the control group, the posttest was performed four weeks after the pretest, between February 26 and March 8, 2024. Completing the questionnaire took 10 to 15 minutes. Measures This study collected data on six general characteristics: age, sex, academic achievement, satisfaction with the major, experience of patient safety education, and experience of patient safety campaigns. Patient safety knowledge was measured using an instrument developed by Park and Park [ 24 ] to examine the extent of patient safety knowledge in nursing college student. This was done after receiving permission from the original authors. The instrument comprised 16 questions in total, with 11 questions developed based on the Korea Institute of Healthcare Accreditation, and 5 questions on classification, concepts, and reporting of healthcare errors. The questions were closed, multiple-choice questions, and high scores indicated better knowledge of patient safety. Patient safety attitude and patient safety performance confidence were measured using an adapted version of the Healthcare Professionals Patient Safety Assessment Curriculum Survey developed by Chenot and Daniel [ 25 ]. This was done after obtaining permission from the original authors. The patient safety attitude instrument consists of 18 questions, scored on a 5-point Likert scale, with higher scores indicating more desirable attitudes towards patient safety. Regarding reliability, the instrument showed Cronbach's α = .660 in the study by Chenot and Daniel [ 25 ], and Cronbach’s ⍺=.852 in our study. The patient safety performance confidence instrument consisted of 5 questions in total, scored on a 5-point Likert scale, with higher scores indicating higher patient safety performance confidence. Regarding reliability, the instrument showed Cronbach's α = .820 in the study by Chenot and Daniel [ 25 ] and Cronbach’s ⍺=.934 in our study. Ethical considerations This study was approved by the institutional review board at the University of Ulsan (IRB No.2024R0001-003). The research participation explanation sheet was distributed online to help participants understand the study, and those who voluntarily consented to participate in the study provided written consent. The collected data was stored on a computer that was only accessible to the investigators. Data analysis The collected data was analyzed using version 24 of the Statistical Package for the Social Sciences (SPSS). General characteristics were analyzed using frequencies, percentage, mean, and standard deviation. The t-test, x2 test, Fisher’s exact test, and Mann-Whitney U test were used to analyze homogeneity between the experimental group and the control group. Within-group differences between the pretest and posttest were analyzed using the means and standard deviations. To compare differences between the groups, we used ANCOVA with the patient safety knowledge score, which was not homogeneous in the pretest, as a covariate. Results Characteristics of the participants After analyzing the homogeneity of the general characteristics and patient safety knowledge, attitude, and performance confidence between the experimental and control groups, no significant differences were found in general characteristics, patient safety attitude, or patient safety performance confidence; however, a significant difference was found in patient safety knowledge (Table 2 ). Table 2 Characteristics of the Participants at Baseline and Comparisons between the Groups (N = 66) Variables Categories Exp.(n = 36) Cont.(n = 30) t or Z/χ2 p n(%)or M ± SD n(%)or M ± SD Age(years) 21.41 ± 1.59 22.96 ± 5.5 -1.491 .145 Sex Male Female 3(8.3) 33(91.7) 4(13.3) 26(86.7) .693‡ Academic achievement ≥ 4.0 3.5 ~ 3.9 3.0 ~ 3.4 ≤ 3.0 11(30.6) 18(50.0) 6(16.7) 1(2.7) 8(26.4) 15(50.0) 4(13.3) 3(10.0) .710‡ Satisfaction with the major High Middle low 27(75.0) 9(25.0) 0(0) 22(73.3) 8(26.7) 0(0) 1.000‡ Experience of patient safety education Yes No 31(86.1) 5(13.9) 27(90.0) 3(10.0) .719‡ Experience of patient safety campaigns Yes No 32(88.9) 4(11.1) 23(23.3) 7(76.7) .206‡ Patient safety knowledge 9.52 ± 1.88 7.93 ± 1.89 -3.392 .001† Patient safety attitude 4.20 ± 0.30 4.10 ± 0.31 − .801 .423† Patient safety performance confidence 4.18 ± 0.50 4.00 ± 0.76 1.155 .254 Exp., Experimental group; Cont., Control group †Mann-Whitney U test, ‡Fisher’s exact test Efficacy outcomes Table 3 shows the results obtained after we tested the efficacy of the ROE simulation for nursing college students. Following education, patient safety knowledge scores in the experimental group increased from 9.52 points to 12.52 points, and the posttest knowledge scores differed significantly between the two groups ( p =.000). Following education, patient safety attitude scores in the experimental group increased from 4.20 points to 4.67 points, with significant differences in the posttest attitude scores between the two groups ( p =.000). Following education, patient safety performance confidence scores in the experimental group increased from 4.18 points to 4.59 points, with significant differences in the posttest knowledge scores between the two groups ( p =.000). Table 3 Staged errors identified in the error room (N = 66) Variables Groups Pre test Post test Difference t p M ± SD M ± SD M ± SD Patient safety knowledge Exp.(n = 36)Cont.(n = 30) 9.52 ± 1.88 7.93 ± 1.89 12.52 ± 2.12 8.13 ± 1.52 2.72 ± 1.98 0.20 ± 1.62 65.959 .000 Patient safety attitude Exp.(n = 36) Cont.(n = 30) 4.20 ± 0.30 4.10 ± 0.31 4.67 ± 0.30 3.98 ± 0.35 0.46 ± 0.28 -0.11 ± 0.36 39.477 .000 Patient safety performance confidence Exp.(n = 36) Cont.(n = 30) 4.18 ± 0.50 4.00 ± 0.76 4.59 ± 0.41 3.86 ± 0.89 0.40 ± 0.47 -0.14 ± 0.65 9.668 .000 Exp., Experimental group; Cont., Control group Discussion In this study, we developed and implemented an ROE simulation for patient safety education, and we investigated the effects of the ROE simulation on patient safety knowledge, attitude, and performance confidence among nursing college students from three different regions preparing for clinical practice. We found that students who participated in the ROE simulation demonstrated significantly greater improvements in patient safety knowledge, attitudes, and performance confidence compared to those who did not participate. Among all participants, the rates of error detection were 91.7% for prescription confirmation errors, 79.2% for medication errors, 79.2% for medical waste management errors, 78.1% for physical injury-related errors, 57.5% for surrounding environment-related errors, and 56.3% for patient identification errors. Kim [ 14 ] also previously reported a high detection rate for medication and prescription-related errors. This is probably because medication and prescription-related safety is strongly emphasized in theoretical and classroom practice education, resulting in high awareness of these errors among students. Conversely, the detection rates for surrounding environment-related errors and patient identification errors were lower, at 50–60%. Undetected errors included the patient wearing the wrong size gown, soiled bed sheets, and high fall risk not being indicated on the patient’s ID bracelet. This suggests that students lacking hospital clinical experience were unaware of the detailed aspects of patients who need to be examined with care. Wearing the wrong size of gown should be noted because it can increase the risk of falls, but this error was only identified by 1 out of the 8 teams. Falls can occur in unexpected situations and diverse surroundings. As such, it is essential to educate nurses on various risk factors in the patient’s surroundings that could cause falls and to provide repeated simulation training that includes fall prevention-related errors [ 14 ]. In our study, we observed that the patient safety knowledge scores increased significantly following patient safety simulation. These findings are consistent with a study by Kim et al. [ 8 ], who also reported increased patient safety knowledge scores after a simulation using patient safety case studies for nursing college students. In the ROE simulation, students directly look for set errors and are debriefed immediately after the simulation. The debriefing process is important, as students analyze the errors and achieve an understanding through discussions and debate. While reflecting on their own practice during the debriefing process, students integrate their knowledge and experience [ 14 , 26 ]. After the ROE simulation, a thorough debriefing should be provided for students to reconfirm their theoretical knowledge and experiences from practice; if the accuracy of knowledge can be improved in this way, it will be effective in improving patient safety competencies. Thus, there is a need to use ROE simulations with systematic debriefing in nursing education. Patient safety attitude scores increased significantly following the patient safety simulation. In a study of medical college students, Madigosky et al. [ 27 ] also reported an overall increase in attitude scores after patient safety education. Park et al. [ 24 ] and Ayyad et al. [ 28 ] reported that patient safety knowledge affects patient safety attitude; conversely, Kim et al. [ 21 ] and Kim et al. [ 8 ] reported that flipped learning in relation to patient safety and case analysis simulation learning have no effects on patient safety attitude. Based on these results, while theoretical classes and case analysis simulation may also be required to improve patient safety attitude, simulation classes that involve identifying patient safety errors in realistic scenarios can also be effective at improving patient safety attitude. Given that a positive attitude to patient safety leads to positive behaviors, it is important to improve patient safety attitudes through appropriate educational methods. We observed a significant increase in patient safety performance confidence scores after the patient safety simulation. Stomski et al. [ 29 ] reported no change in patient safety performance confidence after situational awareness education; they actually reported a decrease in performance confidence after clinical practice. This indicates the importance of education methods for patient safety performance confidence in nursing college students preparing for clinical practice. As situational awareness education by itself cannot sufficiently increase performance confidence, simulation education is also essential, as it allows students to learn through direct and indirect experiences. Students who begin clinical practice with low patient safety confidence may lose even more confidence in front of patients, hindering their ability to receive effective practical education. For students preparing for clinical practice, it is essential to provide education that can improve patient safety performance confidence, including ROE simulations. Students who participated in ROE simulation, communicated to achieve patient safety [ 30 ], and underwent debriefing experienced agency. As they analyzed and criticized their own performance, they were more immersed in the scenarios and, therefore, were thought to have achieved their goals and experienced more confidence than the control group [ 31 ]. Students with high performance confidence are more likely to solve patient safety-related problems rapidly and effectively [ 32 ]. In a study by Gropelli and Shanty [ 1 ], students reported that they were afraid of causing errors with patients and that they would not report their errors because they were afraid of reporting or asking about their own mistakes. This shows the importance of using ROE simulation as a form of education to provide students with the confidence to create environments that are suitable for patient safety. The students who participated in our study expressed very positive opinions about ROE simulation, and we confirmed that this could be an effective educational strategy to improve nursing students’ patient safety knowledge, attitude, and performance confidence. Nurses interact with patients all the time, and they need to be able to recognize threats to patient safety faster than anyone else [ 33 ]. Patient safety education using ROE simulations could be an appropriate educational method to achieve the goal of “patient safety” [ 32 ]. Conclusions We implemented ROE simulation for nursing college students preparing for clinical practice and investigated the changes in patient safety knowledge, attitude, and performance confidence. To examine the effects of ROE simulation, we used a non-equivalent control group pretest-posttest design. We observed significant increases in patient safety knowledge, attitude, and performance confidence among nursing college students who participated in the ROE simulation compared to those who did not participate. These findings demonstrated that ROE simulation is an effective intervention for improving patient safety knowledge, attitude, and performance confidence. Limitations The simulation in this study consisted of a single 45-minute session, which was shorter than sessions in other studies. The length of patient safety lectures and simulations in previous studies varied, and the required length for the intervention to be effective was unclear. In addition, because we did not blind the participants, we cannot exclude the possibility of some small bias. Moreover, because the participants were selected through convenience sampling, there may be some limitations in generalizing the results of our study. Abbreviations PSA Patient safety accident ROE Room of errors Declarations Clinical trial number Not applicable. Acknowledgements The authors are very thankful to all the participants for their valuable contribution. Authors’ contributions Conceptualization, M.K. and S.J.; methodology, M.K. and S.J.; validation, M.K. and S.J.; formal analysis, M.K. and S.J.; data curation, M.K. and S.J.; writing original draft preparation, M.K. and S.J.; writing-review and editing, M.K. and S.J.; supervision, M.K. Funding Not applicable. Availability of data and materials The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki and approved by the institutional review board of Ulsan University (IRB No. 2024R0001-003). After introducing themselves to the students, the researchers explained the study objectives and ensured voluntary participation and the right to withdraw from the study. Informed consent was obtained from the participants, and all methods were carried out in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References Gropelli T, Shanty JA. Nursing students' perceptions of safety and communication issues in the clinical setting. J Nurs Educ. 2018;57:287-90. doi:10.3928/01484834-20180420-06. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Institute of Medicine, Committee on Quality of Health Care in America; 2000. doi:10.17226/9728. 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Effects of “room of errors” simulation education for nursing students on patient safety management behavior intention and confidence in performance. JKSSN. 2023;11:107-20. doi:10.17333/JKSSN.2023.11.2.107. Phillips J, Malliaris AP, Bakerjian D. Nursing and patient safety. PSNet. Rockville (MD): Agency for Healthcare Research and Quality, United States Department of Health and Human Services; 2021. https://psnet.ahrq.gov/primer/nursing-and-patient-safety. Accessed April 21, 2021. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8739568","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587916024,"identity":"d66287ac-9b93-45b5-a10e-db769130c3ac","order_by":0,"name":"Sunmi Jeon","email":"","orcid":"","institution":"daedong university","correspondingAuthor":false,"prefix":"","firstName":"Sunmi","middleName":"","lastName":"Jeon","suffix":""},{"id":587916025,"identity":"e418c875-539b-4626-b63e-e071d05f140d","order_by":1,"name":"Minyoung Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYFACNoYDDBUMMjCuAZFazjDwkKaFgbGNFC26M9ISD92cd5hHvv3sAYYfNQzG5g0EtJjdSDtwOHfbYR6DM3kJjD3HGMxkDhDUkt4A0cKQY8DA28BgI0HIYRAtc4AO639jwPiXOC0ghzUc5mG4kWPADLTFjLCWM88SDuccS+cxuPHG4LDMMQljwlqOpxl/zqmxlpPvzzF8+KbGxnAGIS0MAgkI9gEGBoJ2AAH/ASIUjYJRMApGwcgGABCdPz3T0hjGAAAAAElFTkSuQmCC","orcid":"","institution":"Ulsan University","correspondingAuthor":true,"prefix":"","firstName":"Minyoung","middleName":"","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2026-01-30 09:23:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8739568/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8739568/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102310442,"identity":"9a203fff-0efc-46f7-8c0a-1edd322ef559","added_by":"auto","created_at":"2026-02-10 11:53:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":56125,"visible":true,"origin":"","legend":"\u003cp\u003econceptual framework of the study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8739568/v1/b1b4145b52fb24d0735adf18.png"},{"id":102310813,"identity":"eb8c4f97-ea23-42d8-ac76-5eef9d3d1df1","added_by":"auto","created_at":"2026-02-10 11:56:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65821,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of individuals included in the analysis\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8739568/v1/3beb7a2b9013ac421af4337a.png"},{"id":107486809,"identity":"74952b49-5efd-41e8-a11d-9b9ee0eeafe5","added_by":"auto","created_at":"2026-04-22 02:39:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":506910,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8739568/v1/bc89c849-4b2f-4057-89e4-1fe57d387738.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of room of errors simulation in patient safety education for nursing students preparing for clinical practice: A quasi-experimental study focusing on three regions in South Korea","fulltext":[{"header":"Background","content":"\u003cp\u003eSince the Institute of Medicine in the US published a report, titled \u0026ldquo;To Err is Human: Building a Safer Health System\u0026rdquo; that stated that patient safety accidents (PSAs) cause 98,000 deaths and over 1,000,000 injuries per year, PSAs have become a major topic of interest in healthcare [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. PSAs are currently the third leading cause of death for patients in hospitals in the US [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and as many as 4 in 100 people die from PSAs in some countries [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn analysis of PSAs reported to the Korea Patient Safety Reporting and Learning System between 2016 and 2024 revealed that 41.6% were due to falls, and 38.6% were medication errors [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Thus, PSAs are an especially important problem for nurses, who interact closely with patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Frequently, PSAs occur because of mistakes or careless behaviors by nurses. Such behaviors can cause diverse outcomes in patients, from mild problems to death, and also cause economic damages to the hospital or country because of high medical costs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, error-free nursing is required based on principles and concepts related to patient safety. Given the importance of PSAs, education on patient safety is essential for nurses [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimulation is a technique that has recently been favored in nursing education as a conversational learning method that provides participants with the required knowledge, skills, and attitude in a highly realistic virtual environment [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Types of simulation include virtual reality, augmented reality, high-fidelity, and low-fidelity [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Of these, low-fidelity simulation is preferred, because it is relatively inexpensive, efficient, and does not require expensive equipment or expert skills. Rooms of errors (ROEs) can be run as low-fidelity simulations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. An ROE, a concept developed at the University of Virginia, is a simulation in which patient safety issues are set up in various hospital environments to be resolved by the participants [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. ROEs are indirect patient safety simulations in which participants enter an error-filled environment and must identify as many issues or hazards as possible. Examples of errors might include an incorrect patient name band, fall-related risk factors, or errors relating to medication [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. ROEs offer valuable hands-on experience in identifying issues and recognizing potential risks to patient safety. As ROEs are based on simple scenarios, and various clinical errors can be set up, they can be implemented easily, even by instructors with minimal experience in developing scenarios and running simulations [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eROE scenarios are constructed based on commonly reported PSAs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. ROE participants can be individuals or teams, but teams are more effective [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Participants can be diverse, including nursing students and medical students, as well as nurses, doctors, and hospital staff [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In previous studies, participant satisfaction was high, and ROEs were effective at improving situational awareness and patient safety awareness [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. ROEs allow students to integrate their knowledge and experience, by participating in the process of identifying and fixing their own errors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. ROEs also stimulate students\u0026rsquo; interest and increase participation in practice, suggesting that they are an efficient form of patient safety education [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The objectives of patient safety education for nursing students are to acquire patient safety competencies and to learn and practice the concept and principles of patient safety [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The importance of patient safety education is increasingly being recognized by nursing colleges, creating a need for research into effective teaching methods and learning strategies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs such, this study aimed to develop ROE simulations for students at three different nursing colleges preparing for clinical practice and to investigate the effects of the ROE simulations on students\u0026rsquo; patient safety knowledge, attitudes, and performance confidence.\u003c/p\u003e\n\u003ch3\u003eAim of the study\u003c/h3\u003e\n\u003cp\u003eThe purpose of this study was to investigate the effects of ROE simulations on the patient safety knowledge, patient safety attitude, and patient safety performance confidence of nursing college students preparing for clinical practice.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Hypothesis\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eHypothesis 1\u003c/strong\u003e \u003cp\u003eThe group that participated in the ROE simulation (experimental group) will show improved patient safety knowledge compared to the control group.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis 2\u003c/strong\u003e \u003cp\u003eThe group that participated in the ROE simulation (experimental group) will show an improved patient safety attitude compared to the control group.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis 3\u003c/strong\u003e \u003cp\u003eThe group that participated in the ROE simulation (experimental group) will show improved patient safety performance confidence compared to the control group.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis was a quasi-experimental study with a non-equivalent control group pretest-posttest design, with the objective of testing the effects of ROE simulation on patient safety knowledge, patient safety attitude, and patient safety performance confidence in nursing college students (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and setting\u003c/h3\u003e\n\u003cp\u003eThis study\u0026rsquo;s participants were third-year students in nursing colleges, preparing for clinical practice. We used convenience sampling to recruit students from three regions with similar curricula. To prevent contamination effects, we recruited control group participants from a nursing college in another city via the department homepage. The specific inclusion criteria were: 1) third-year nursing college students who had completed a classroom practical course; 2) having no experience of ROE simulation education; 3) having no experience of clinical practice.\u003c/p\u003e \u003cp\u003eTo calculate the number of participants, with reference to previous studies [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], we used G*power 3.1 with an effect size\u0026thinsp;=\u0026thinsp;0.8, power (1-β)\u0026thinsp;=\u0026thinsp;0.9, and confidence level=.05. To account for a dropout rate of 25.0%, we recruited 72 participants, with 36 participants in each group.\u003c/p\u003e\n\u003ch3\u003eStudy sample\u003c/h3\u003e\n\u003cp\u003eAll 36 persons in the experimental group participated in the posttest immediately after the intervention (dropout rate, 0.0%). Of the 36 persons in the control group, 6 did not participate in the posttest (dropout rate, 16.7%). Thus, data from 66 persons in total (experimental group: 36 persons, control group: 30 persons) was used in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInterventions and procedures\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eDevelopment of the ROE simulation\u003c/h2\u003e \u003cp\u003eFor the ROE simulation, we developed a scenario with errors related to patient safety and named it the \u0026ldquo;Go Out! Room of Errors\u0026rdquo; The scenario entailed checking for errors during the hospitalization of a 77-year-old male patient diagnosed with hypertension and diabetes. The medical records provided in advance were progress records, hospitalization records, doctor\u0026rsquo;s orders, and nursing records.\u003c/p\u003e \u003cp\u003eBased on previous studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], patient safety-related errors were divided into 6 categories: physical injury errors, surrounding environment errors, medication errors, patient identification errors, medical waste management errors, and prescription confirmation errors. There were 23 errors in total across these categories (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eErrors staged in the room of errors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStaged safety errors\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003ePhysical injury errors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA needle and alcohol swab were in the bed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe urine bag was being dragged on the floor while the patient had a Foley catheter inserted.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA Foley catheter was wrapped around the bedside rail.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe bedside rail was not raised.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe bed wheels were not locked.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThere was no sign indicating high fall risk for patients aged 65 or older.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWater was spilled on the floor around the bed (wet floor for a high fall risk patient).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eSurrounding environment errors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe patient was not wearing their hospital clothes properly (incorrect trouser length).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe bedsheets were soiled with the patient\u0026rsquo;s urine.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThere was cigarettes and alcohol on the bedside table.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElectronic devices (such as electric kettle and heated mats) were being used.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe hand sanitizer dispenser was empty.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMedication errors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoth RBC blood pack and fluid bag drips were attached (duplicate medication).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe patient\u0026rsquo;s blood type and the transfusion blood type did not match.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe fluids were past their use-by date.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePatient identification errors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe patient\u0026rsquo;s name did not match the name on the patient chart.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh fall risk was not indicated on the patient\u0026rsquo;s ID bracelet.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMedical waste\u003c/p\u003e \u003cp\u003emanagement errors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA needle was discarded in the general waste box.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBloodstained gloves and gauze were discarded in the regular waste basket.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe ward\u0026rsquo;s waste basket was overflowing.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePrescription confirmation errors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe dose of O2 being provided did not match the prescription.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe medication being administered did not match the prescription.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAn AST-positive antibiotic (positive drug response test) was prescribed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003ePretest\u003c/h3\u003e\n\u003cp\u003eThe pretest was conducted between February 1 and February 11, 2024. The participants first completed a consent form and then the pretest questionnaire, which took approximately 10 to 15 minutes.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003eThe ROE simulation was run on March 7, 2024, less than 4 weeks after the pretest. The experimental group was divided into 9 teams of 4 students each for the intervention, and the intervention took around 45 minutes per team. During a 10-minute orientation, the investigators explained the plans for the intervention, precautions during the ROE simulation, and the methods for finding and reporting errors. Thereafter, the participants were given 15 minutes to enter the ROE, find errors related to patient safety, and complete the reporting form. Team members were allowed to discuss with one another, and one research assistant was situated in the ROE to provide instructions. Finally, there was a 20-minute debriefing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePosttest\u003c/h2\u003e \u003cp\u003eThe posttest for the experimental group was performed immediately after the intervention, led by a research assistant. For the control group, the posttest was performed four weeks after the pretest, between February 26 and March 8, 2024. Completing the questionnaire took 10 to 15 minutes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003eThis study collected data on six general characteristics: age, sex, academic achievement, satisfaction with the major, experience of patient safety education, and experience of patient safety campaigns.\u003c/p\u003e \u003cp\u003ePatient safety knowledge was measured using an instrument developed by Park and Park [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] to examine the extent of patient safety knowledge in nursing college student. This was done after receiving permission from the original authors. The instrument comprised 16 questions in total, with 11 questions developed based on the Korea Institute of Healthcare Accreditation, and 5 questions on classification, concepts, and reporting of healthcare errors. The questions were closed, multiple-choice questions, and high scores indicated better knowledge of patient safety.\u003c/p\u003e \u003cp\u003ePatient safety attitude and patient safety performance confidence were measured using an adapted version of the Healthcare Professionals Patient Safety Assessment Curriculum Survey developed by Chenot and Daniel [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This was done after obtaining permission from the original authors. The patient safety attitude instrument consists of 18 questions, scored on a 5-point Likert scale, with higher scores indicating more desirable attitudes towards patient safety. Regarding reliability, the instrument showed Cronbach's α\u0026thinsp;=\u0026thinsp;.660 in the study by Chenot and Daniel [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and Cronbach\u0026rsquo;s ⍺=.852 in our study. The patient safety performance confidence instrument consisted of 5 questions in total, scored on a 5-point Likert scale, with higher scores indicating higher patient safety performance confidence. Regarding reliability, the instrument showed Cronbach's α\u0026thinsp;=\u0026thinsp;.820 in the study by Chenot and Daniel [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and Cronbach\u0026rsquo;s ⍺=.934 in our study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e This study was approved by the institutional review board at the University of Ulsan (IRB No.2024R0001-003). The research participation explanation sheet was distributed online to help participants understand the study, and those who voluntarily consented to participate in the study provided written consent. The collected data was stored on a computer that was only accessible to the investigators.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe collected data was analyzed using version 24 of the Statistical Package for the Social Sciences (SPSS). General characteristics were analyzed using frequencies, percentage, mean, and standard deviation. The t-test, x2 test, Fisher\u0026rsquo;s exact test, and Mann-Whitney U test were used to analyze homogeneity between the experimental group and the control group. Within-group differences between the pretest and posttest were analyzed using the means and standard deviations. To compare differences between the groups, we used ANCOVA with the patient safety knowledge score, which was not homogeneous in the pretest, as a covariate.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the participants\u003c/h2\u003e \u003cp\u003eAfter analyzing the homogeneity of the general characteristics and patient safety knowledge, attitude, and performance confidence between the experimental and control groups, no significant differences were found in general characteristics, patient safety attitude, or patient safety performance confidence; however, a significant difference was found in patient safety knowledge (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the Participants at Baseline and Comparisons between the Groups (N\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExp.(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCont.(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003et or Z/χ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en(%)or M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en(%)or M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.96\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(8.3)\u003c/p\u003e \u003cp\u003e33(91.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(13.3)\u003c/p\u003e \u003cp\u003e26(86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.693\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic achievement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4.0\u003c/p\u003e \u003cp\u003e3.5\u0026thinsp;~\u0026thinsp;3.9\u003c/p\u003e \u003cp\u003e3.0\u0026thinsp;~\u0026thinsp;3.4\u003c/p\u003e \u003cp\u003e\u0026le;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(30.6)\u003c/p\u003e \u003cp\u003e18(50.0)\u003c/p\u003e \u003cp\u003e6(16.7)\u003c/p\u003e \u003cp\u003e1(2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(26.4)\u003c/p\u003e \u003cp\u003e15(50.0)\u003c/p\u003e \u003cp\u003e4(13.3)\u003c/p\u003e \u003cp\u003e3(10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.710\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction with the major\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003cp\u003elow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(75.0)\u003c/p\u003e \u003cp\u003e9(25.0)\u003c/p\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22(73.3)\u003c/p\u003e \u003cp\u003e8(26.7)\u003c/p\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience of patient safety education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31(86.1)\u003c/p\u003e \u003cp\u003e5(13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27(90.0)\u003c/p\u003e \u003cp\u003e3(10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.719\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience of patient safety campaigns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32(88.9)\u003c/p\u003e \u003cp\u003e4(11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23(23.3)\u003c/p\u003e \u003cp\u003e7(76.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.206\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient safety knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.001\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient safety attitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.423\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient safety\u003c/p\u003e \u003cp\u003eperformance confidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.254\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eExp., Experimental group; Cont., Control group\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u0026dagger;Mann-Whitney U test, \u0026Dagger;Fisher\u0026rsquo;s exact test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eEfficacy outcomes\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the results obtained after we tested the efficacy of the ROE simulation for nursing college students. Following education, patient safety knowledge scores in the experimental group increased from 9.52 points to 12.52 points, and the posttest knowledge scores differed significantly between the two groups (\u003cem\u003ep\u003c/em\u003e=.000). Following education, patient safety attitude scores in the experimental group increased from 4.20 points to 4.67 points, with significant differences in the posttest attitude scores between the two groups (\u003cem\u003ep\u003c/em\u003e=.000). Following education, patient safety performance confidence scores in the experimental group increased from 4.18 points to 4.59 points, with significant differences in the posttest knowledge scores between the two groups (\u003cem\u003ep\u003c/em\u003e=.000).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStaged errors identified in the error room (N\u0026thinsp;=\u0026thinsp;66)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDifference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient safety knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExp.(n\u0026thinsp;=\u0026thinsp;36)Cont.(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003cp\u003e7.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.52\u0026thinsp;\u0026plusmn;\u0026thinsp;2.12\u003c/p\u003e \u003cp\u003e8.13\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e \u003cp\u003e0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e65.959\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient safety attitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExp.(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003cp\u003eCont.(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e \u003cp\u003e4.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e \u003cp\u003e3.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e \u003cp\u003e-0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39.477\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient safety\u003c/p\u003e \u003cp\u003eperformance confidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExp.(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003cp\u003eCont.(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003cp\u003e4.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e \u003cp\u003e3.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47\u003c/p\u003e \u003cp\u003e-0.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.668\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eExp., Experimental group; Cont., Control group\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we developed and implemented an ROE simulation for patient safety education, and we investigated the effects of the ROE simulation on patient safety knowledge, attitude, and performance confidence among nursing college students from three different regions preparing for clinical practice. We found that students who participated in the ROE simulation demonstrated significantly greater improvements in patient safety knowledge, attitudes, and performance confidence compared to those who did not participate.\u003c/p\u003e \u003cp\u003eAmong all participants, the rates of error detection were 91.7% for prescription confirmation errors, 79.2% for medication errors, 79.2% for medical waste management errors, 78.1% for physical injury-related errors, 57.5% for surrounding environment-related errors, and 56.3% for patient identification errors. Kim [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] also previously reported a high detection rate for medication and prescription-related errors. This is probably because medication and prescription-related safety is strongly emphasized in theoretical and classroom practice education, resulting in high awareness of these errors among students. Conversely, the detection rates for surrounding environment-related errors and patient identification errors were lower, at 50\u0026ndash;60%. Undetected errors included the patient wearing the wrong size gown, soiled bed sheets, and high fall risk not being indicated on the patient\u0026rsquo;s ID bracelet. This suggests that students lacking hospital clinical experience were unaware of the detailed aspects of patients who need to be examined with care. Wearing the wrong size of gown should be noted because it can increase the risk of falls, but this error was only identified by 1 out of the 8 teams. Falls can occur in unexpected situations and diverse surroundings. As such, it is essential to educate nurses on various risk factors in the patient\u0026rsquo;s surroundings that could cause falls and to provide repeated simulation training that includes fall prevention-related errors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, we observed that the patient safety knowledge scores increased significantly following patient safety simulation. These findings are consistent with a study by Kim et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], who also reported increased patient safety knowledge scores after a simulation using patient safety case studies for nursing college students. In the ROE simulation, students directly look for set errors and are debriefed immediately after the simulation. The debriefing process is important, as students analyze the errors and achieve an understanding through discussions and debate. While reflecting on their own practice during the debriefing process, students integrate their knowledge and experience [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. After the ROE simulation, a thorough debriefing should be provided for students to reconfirm their theoretical knowledge and experiences from practice; if the accuracy of knowledge can be improved in this way, it will be effective in improving patient safety competencies. Thus, there is a need to use ROE simulations with systematic debriefing in nursing education.\u003c/p\u003e \u003cp\u003ePatient safety attitude scores increased significantly following the patient safety simulation. In a study of medical college students, Madigosky et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] also reported an overall increase in attitude scores after patient safety education. Park et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and Ayyad et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] reported that patient safety knowledge affects patient safety attitude; conversely, Kim et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and Kim et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] reported that flipped learning in relation to patient safety and case analysis simulation learning have no effects on patient safety attitude. Based on these results, while theoretical classes and case analysis simulation may also be required to improve patient safety attitude, simulation classes that involve identifying patient safety errors in realistic scenarios can also be effective at improving patient safety attitude. Given that a positive attitude to patient safety leads to positive behaviors, it is important to improve patient safety attitudes through appropriate educational methods.\u003c/p\u003e \u003cp\u003eWe observed a significant increase in patient safety performance confidence scores after the patient safety simulation. Stomski et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] reported no change in patient safety performance confidence after situational awareness education; they actually reported a decrease in performance confidence after clinical practice. This indicates the importance of education methods for patient safety performance confidence in nursing college students preparing for clinical practice. As situational awareness education by itself cannot sufficiently increase performance confidence, simulation education is also essential, as it allows students to learn through direct and indirect experiences. Students who begin clinical practice with low patient safety confidence may lose even more confidence in front of patients, hindering their ability to receive effective practical education. For students preparing for clinical practice, it is essential to provide education that can improve patient safety performance confidence, including ROE simulations.\u003c/p\u003e \u003cp\u003eStudents who participated in ROE simulation, communicated to achieve patient safety [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and underwent debriefing experienced agency. As they analyzed and criticized their own performance, they were more immersed in the scenarios and, therefore, were thought to have achieved their goals and experienced more confidence than the control group [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Students with high performance confidence are more likely to solve patient safety-related problems rapidly and effectively [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In a study by Gropelli and Shanty [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], students reported that they were afraid of causing errors with patients and that they would not report their errors because they were afraid of reporting or asking about their own mistakes. This shows the importance of using ROE simulation as a form of education to provide students with the confidence to create environments that are suitable for patient safety.\u003c/p\u003e \u003cp\u003eThe students who participated in our study expressed very positive opinions about ROE simulation, and we confirmed that this could be an effective educational strategy to improve nursing students\u0026rsquo; patient safety knowledge, attitude, and performance confidence. Nurses interact with patients all the time, and they need to be able to recognize threats to patient safety faster than anyone else [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Patient safety education using ROE simulations could be an appropriate educational method to achieve the goal of \u0026ldquo;patient safety\u0026rdquo; [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe implemented ROE simulation for nursing college students preparing for clinical practice and investigated the changes in patient safety knowledge, attitude, and performance confidence. To examine the effects of ROE simulation, we used a non-equivalent control group pretest-posttest design. We observed significant increases in patient safety knowledge, attitude, and performance confidence among nursing college students who participated in the ROE simulation compared to those who did not participate. These findings demonstrated that ROE simulation is an effective intervention for improving patient safety knowledge, attitude, and performance confidence.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe simulation in this study consisted of a single 45-minute session, which was shorter than sessions in other studies. The length of patient safety lectures and simulations in previous studies varied, and the required length for the intervention to be effective was unclear. In addition, because we did not blind the participants, we cannot exclude the possibility of some small bias. Moreover, because the participants were selected through convenience sampling, there may be some limitations in generalizing the results of our study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient safety accident\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoom of errors\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are very thankful to all the participants for their valuable contribution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, M.K. and S.J.; methodology, M.K. and S.J.; validation, M.K. and S.J.; formal analysis, M.K. and S.J.; data curation, M.K. and S.J.; writing original draft preparation, M.K. and S.J.; writing-review and editing, M.K. and S.J.; supervision, M.K.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the institutional review board of Ulsan University (IRB No. 2024R0001-003). After introducing themselves to the students, the researchers explained the study objectives and ensured voluntary participation and the right to withdraw from the study. Informed consent was obtained from the participants, and all methods were carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGropelli T, Shanty JA. Nursing students\u0026apos; perceptions of safety and communication issues in the clinical setting. J Nurs Educ. 2018;57:287-90. doi:10.3928/01484834-20180420-06.\u003c/li\u003e\n \u003cli\u003eKohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Institute of Medicine, Committee on Quality of Health Care in America; 2000. doi:10.17226/9728.\u003c/li\u003e\n \u003cli\u003eMakary MA, Daniel M. 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Knowledge, attitudes, and practices toward Patient Safety among nurses in health centers. BMC Nurs. 2024;23:171. doi:10.1186/s12912-024-01831-1.\u003c/li\u003e\n \u003cli\u003eStomski N, Gluyas H, Andrus P, Williams A, Hopkins M, Walters J, et al. The influence of situation awareness training on nurses\u0026apos; confidence about patient safety skills: a prospective cohort study. Nurse Educ Today. 2018;63:24-8. doi:10.1016/j.nedt.2018.01.019.\u003c/li\u003e\n \u003cli\u003eKim E-J, Nam K-A. Effects of team-based simulation training on patient safety confidence and nursing competency among nursing students. J East-West Nurs Res. 2020;26:130-8. doi:10.14370/jewnr.2020.26.2.130.\u003c/li\u003e\n \u003cli\u003eKo S-J, Choi E-H. Effect of team debriefing in simulation-based cardiac arrest emergency nursing education. Korean J Adult Nurs. 2017;29:667-76. doi:10.7475/kjan.2017.29.6.667.\u003c/li\u003e\n \u003cli\u003eJung S-Y, Kim H-J, Lee E-K, Park J-H. Effects of \u0026ldquo;room of errors\u0026rdquo; simulation education for nursing students on patient safety management behavior intention and confidence in performance. JKSSN. 2023;11:107-20. doi:10.17333/JKSSN.2023.11.2.107.\u003c/li\u003e\n \u003cli\u003ePhillips J, Malliaris AP, Bakerjian D. Nursing and patient safety. PSNet. Rockville (MD): Agency for Healthcare Research and Quality, United States Department of Health and Human Services; 2021. https://psnet.ahrq.gov/primer/nursing-and-patient-safety. Accessed April 21, 2021.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Patient Safety, Medical Errors, Room of Errors, Simulation Training, Nursing Students","lastPublishedDoi":"10.21203/rs.3.rs-8739568/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8739568/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePatient accidents are an important problem in healthcare, and patient safety education for nurses is essential to prevent such accidents. Room of errors simulation is a low-cost, high-efficiency method used in nursing education that helps students improve their ability to recognize and resolve errors related to patient safety. This study aimed to develop and implement a room of errors simulation for nursing students preparing for clinical practice and to evaluate the effects on students\u0026rsquo; patient safety knowledge, attitude, and performance confidence.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a quasi-experimental study with a non-equivalent control group pretest-posttest design. The participants comprised 66 students from 3 different nursing colleges in South Korea. The collected data included demographic information, patient safety knowledge, patient safety attitude, and patient safety performance confidence. Data was collected in February and March 2024 and was analyzed using SPSS version 24.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn total, 66 nursing students were included in the analysis. After completing the room of errors simulation, compared to the control group, the experimental group showed significantly improved scores for patient safety knowledge (t\u0026thinsp;=\u0026thinsp;65.959, p=.000), patient safety attitude (t\u0026thinsp;=\u0026thinsp;39.477, p=.000), and patient safety performance confidence (t\u0026thinsp;=\u0026thinsp;9.668, p=.000).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe room of errors simulation effectively increased patient safety knowledge, patient safety attitude, and patient safety performance confidence in nursing college students preparing for clinical practice.\u003c/p\u003e","manuscriptTitle":"Effectiveness of room of errors simulation in patient safety education for nursing students preparing for clinical practice: A quasi-experimental study focusing on three regions in South Korea","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 11:42:00","doi":"10.21203/rs.3.rs-8739568/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4e5621a-7e5b-4b4b-99c6-7c6f6b601375","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T07:42:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 11:42:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8739568","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8739568","identity":"rs-8739568","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}