Patient safety is defined as reducing the risk of preventable harm associated with healthcare to an acceptable minimum [1]. To achieve this standard, nurses must possess patient safety competency-the integrated knowledge, skills, and attitudes essential for identifying risks, preventing errors, and ensuring optimal patient outcomes [2].

Despite heightened focus on patient safety, incident rates continue to rise. Data from the Korea Patient Safety Reporting and Learning System (KOPS) 2022 Patient Safety Statistics Yearbook reveals a consistent upward trend, with reported incidents increasing from 9,250 in 2018 to 14,820 in 2022, representing a 12.5% compound annual growth rate [3]. In response, the government launched the Second Patient Safety Plan (2023∼2027), which emphasizes information communications technology (ICT) and artificial intelligence (AI) integration for patient safety systems, establishment of monitoring frameworks for technology implementation, and comprehensive strategies to enhance institutional safety management [4].

Clinical practice is undergoing rapid digital transformation through widespread adoption of electronic health records and ICT integration. This technological shift enhances patient safety by streamlining nursing workflows, reducing documentation burden, facilitating evidence-based decision-making, and minimizing medication errors [5]. As primary users of health information systems, nurses are positioned at the nexus of digital healthcare innovation. Nursing informatics competency refers to the knowledge, skills, and abilities required to effectively use health information systems and digital technologies in nursing practice to support patient care and clinical decision-making [6]. According to previous studies, nurses with high informatics competency effectively utilize electronic health record systems and barcode medication administration systems to significantly reduce medication errors [7]. Moreover, they demonstrate superior patient documentation performance through proficient use of electronic health record systems, thereby contributing to improved patient safety [8]. Conversely, insufficient nursing informatics competency has been identified as a major cause of technology-related patient safety incidents. Studies have shown that a considerable proportion of medication errors are associated with inappropriate use or workaround practices in barcode medication administration systems. This suggests that the mere adoption of technology is insufficient; improving nurses’ informatics competency is essential to ensure the safe and effective use of such systems [9]. Additionally, nurses with higher informatics competency demonstrate enhanced clinical decision-making abilities through systematic patient data analysis [10].

Nurses must gather comprehensive patient data across diverse clinical contexts and apply evidence-based reasoning to inform clinical decisions [11]. The increasingly complex healthcare environment, coupled with rising patient acuity levels, has intensified both the frequency and criticality of nursing decision-making [12]. ICT advances require nurses to synthesize complex patient data and make timely, evidence-based decisions regarding patient monitoring, care planning, and health assessment [13]. Clinical decision-making is a cognitive process whereby nurses identify patient problems and select optimal interventions [14]. Modern nursing practice demands integration of clinical expertise with systematic health information system data to reduce care-related errors [15]. Conversely, deficient clinical decision-making processes, manifesting as compromised situational assessment and suboptimal clinical judgment, have demonstrated significant associations with adverse patient safety outcomes; therefore, robust clinical decision-making capabilities are significantly associated with patient safety competency [16].

Nurses’ patient safety competency serves as an indicator of organizational safety culture [17], making its enhancement critical in healthcare settings prioritizing patient safety. While nursing informatics competency [18,19] and clinical decision-making ability [20] are recognized predictors of patient safety competency, limited research has examined these relationships among practicing nurses. Moreover, existing studies on the impact of clinical decision-making ability lack sufficient diversity in settings and populations to establish generalizability. Although nursing informatics competency and clinical decision-making ability are important factors that may influence patient safety outcomes, comprehensive research examining their combined effects on patient safety competency remains limited. Several demographic and work-related factors were also examined in relation to patient safety competency

This study evaluated nursing informatics competency, clinical decision-making ability, and patient safety competency among clinical nurses, examining their interrelationships and identifying factors associated with patient safety competency.

This cross-sectional descriptive study examined the relationships among nursing informatics competency, clinical decision-making ability, and patient safety competency, providing insights for enhancing patient safety practices in clinical nursing.

Participants demonstrated moderate nursing informatics competency (M=2.67/4.0), comparable to previous findings in tertiary hospital nurses (2.65) [26] but lower than mixed hospital samples (2.88) [19]. While direct comparisons are limited by the recent development of this instrument, our findings align with or fall slightly below previous reports. This pattern likely reflected generational differences in formal informatics training. Unlike previous samples with 50% of participants in their twenties, over 60% of our participants were thirty or older. Although nursing informatics has become increasingly integrated into nursing curricula [27], many practicing nurses completed their education before such content was standard. These findings highlight opportunities for workplace-based training to address nursing informatics competency gaps among experienced nurses.

Clinical decision-making ability scores (M=3.33/5.0) closely paralleled previous reports using identical measures in tertiary (3.35) [28] and general hospital settings (3.34) [29]. This consistency across studies with similar demographic profiles suggests stable patterns in clinical decision-making ability development. The literature consistently demonstrates that clinical decision-making ability evolves with experience and exposure to complex clinical situations. Our findings reinforce that early-career nurses may benefit from structured support for developing clinical decision-making ability. Simulation-based learning and collaborative problem-solving with experienced colleagues offer promising approaches for accelerating clinical decision-making ability among novice practitioners.

Patient safety competency scores (M=4.04/5.0) exceeded previous reports in comparable settings (3.83) [30] while approximating others (4.06) [19]. This upward trend coincides with intensified patient safety initiatives, including mandatory accreditation standards and systematic safety education programs. The relatively high patient safety competency baseline suggests that organizational safety cultures have matured considerably over recent years.

Univariate analyses revealed significant variations in patient safety competency across demographic characteristics. Nurses aged 30∼39 demonstrated higher patient safety competency than those under 30, mirroring previous findings [30]. This age-related pattern suggests that patient safety competency develops through accumulated experience and exposure to safety-critical situations. Structured mentoring may accelerate patient safety competency development among early-career nurses [31]. Educational attainment similarly predicted patient safety competency, consistent with prior research [19,30], suggesting that advanced education enhances safety-related knowledge and skills. Special unit nurses outperformed general ward colleagues in patient safety competency, likely reflecting their frequent engagement with high-acuity situations requiring rapid assessment and intervention. Cross-training initiatives might disseminate these competencies more broadly. Interestingly, while QI participation initially correlated with patient safety competency, this relationship dissipated after controlling for nursing informatics competency and clinical decision-making ability, suggesting mediation through skill development rather than direct effects.

Correlation analyses confirmed positive associations among all three competencies. The observed relationships between nursing informatics competency and patient safety competency align with previous investigations [18,22], as do correlations between clinical decision-making ability and patient safety competency [20]. In contemporary healthcare environments, nurses with high nursing informatics competency leverage technology to enhance safety monitoring and error prevention. Similarly, strong clinical decision-making ability enables nurses to integrate multiple data sources, anticipate complications, and prioritize interventions that minimize patient harm [11].

Hierarchical multiple regression analyses revealed nuanced relationships among study variables. Clinical decision-making ability and nursing informatics competency emerged as equally powerful predictors of patient safety competency (both β=.38, p<.001), with special unit assignment providing additional predictive value (β=.18, p=.001). The staged model-building approach illuminated the substantial contribution of nursing informatics competency, which alone increased explained variance by 21.4%. This dramatic improvement underscores the central role of nursing informatics competency in contemporary safety practices. The subsequent addition of clinical decision-making ability contributed an additional 11.6%, yielding a robust final model explaining 42.8% of patient safety competency variance.

Particularly noteworthy was the apparent mediation of demographic effects through nursing informatics competency. Educational level and job satisfaction, initially significant predictors of patient safety competency, lost significance upon introducing nursing informatics competency. This pattern suggests that demographic advantages may operate through enhanced technology adoption and utilization rather than directly influencing patient safety competency. Formal mediation testing would clarify these indirect pathways.

The equivalent standardized coefficients for clinical decision-making ability and nursing informatics competency challenge hierarchical assumptions about their relative importance for patient safety competency. Rather than competing influences, these competencies appeared complementary, each contributing unique variance to patient safety competency outcomes. This finding aligns with contemporary frameworks positioning patient safety competency as a complex phenomenon requiring both technical proficiency and clinical judgment [14,20].

The persistent significance of special unit assignment across all models warrants particular attention. Unlike demographic variables that lost significance, special unit assignment actually strengthened (β increased from .12 to .18), indicating environmental contributions to patient safety competency independent of individual competencies. Special units may provide structural advantages—lower patient ratios, advanced monitoring systems, interdisciplinary collaboration, and continuous education—that inherently support patient safety competency. This environmental effect suggests that developing individual nursing informatics competency and clinical decision-making ability alone may be insufficient; organizational structures and processes equally influence patient safety competency outcomes.

These findings carry implications for nursing education and practice development. The strong associations between nursing informatics competency, clinical decision-making ability, and patient safety competency suggest that initiatives targeting these competencies may yield safety improvements. Virtual simulation platforms, clinical decision support systems, and case-based learning approaches represent promising strategies for enhancing both nursing informatics competency and clinical decision-making ability. These systems include automated fall risk assessment tools that integrate patient mobility scores, medication profiles, and nursing assessments to generate real-time alerts, as well as medication safety systems that flag potential adverse drug reactions and suggest appropriate nursing monitoring parameters.

These findings provide empirical evidence supporting South Korea's Second National Patient Safety Comprehensive Plan (2023∼2027) [4]. The equally strong predictive power of nursing informatics competency and clinical decision-making ability (both β=.38, p<.001) indicates that achieving the government's target of increasing patient safety personnel deployment from 25% (2022) to 40% (2027) [4] requires systematic competency development alongside workforce expansion. Furthermore, the independent effect of special unit assignment (β=.18) underscores the importance of infrastructure enhancement for small and medium-sized healthcare institutions, demonstrating that both individual competency development and organizational support are essential for improving patient safety outcomes.

However, our cross-sectional design precludes causal conclusions; observed associations may reflect bidirectional relationships or unmeasured confounds. While our model explained 42.8% of variance in patient safety competency, the substantial unexplained variance suggests that additional factors beyond individual competencies may influence patient safety outcomes. These potentially include organizational and systemic variables not measured in this study.

Several limitations warrant consideration. The cross-sectional design limits interpretation to associations rather than causal relationships among nursing informatics competency, clinical decision-making ability, and patient safety competency. The study sample was recruited predominantly from hospitals in Province J, with limited supplementary recruitment via online professional communities. This geographical concentration presents several limitations to the generalizability of findings. First, the healthcare infrastructure, informatics adoption levels, and patient safety culture specific to Province J may not be representative of national patterns. Second, the concentration of participants from a single regional healthcare system may have systematically influenced the measured competencies in ways that differ from other regions with disparate resources and organizational contexts. Third, the distribution of nursing specialties within the sampled hospitals may not reflect the national nursing workforce composition, which could affect the observed relationships among study variables. Future research should employ multi-site stratified random sampling across diverse geographical regions to establish the external validity of these findings. Self-report measures of patient safety competency, while efficient, may introduce social desirability bias or inaccurately capture actual competencies. Future investigations should employ longitudinal designs to establish temporal precedence, incorporate objective assessments of patient safety competency, and examine whether enhancement of nursing informatics competency and clinical decision-making ability translates to measurable patient safety outcomes.

This study identified nursing informatics competency, clinical decision-making ability, and special care unit assignment as significant predictors of patient safety competency among clinical nurses, with the two competencies demonstrating equally strong associations. These findings suggest that both technical and cognitive competencies may be potentially important for patient safety outcomes in digital healthcare environments. Future research should examine whether interventions targeting these competencies translate to measurable improvements in patient safety outcomes.