Patient safety aims to prevent harm during care delivery, while safety incidents include all clinical errors or failures, regardless of whether patient injury occurs [1]. Given that patient safety incidents can pose serious threats to patients’ lives, they are regarded as essential benchmarks for evaluating healthcare quality. Therefore, healthcare institutions must prioritize patient safety by establishing clear criteria and adopting structured management strategies.

In South Korea, hospital-level patient safety guidelines have been developed based on national accreditation standards that were shaped by U.S. evaluation models. These standards were introduced to improve safety systems and promote a stronger culture of safety within healthcare settings [2]. The major influence was the Joint Commission, which outlined 14 safety goals, including proper patient identification, safe medication administration, and infection control [3]. Reflecting these international efforts, Korea began including patient safety in hospital evaluations in 2004 and made it a required component of the national accreditation program by 2010. These changes have strengthened safety practices at the institutional level and increased awareness among healthcare workers [4].

Recent changes in healthcare policy and accreditation have made nurses more central to ensuring patient safety. In daily practice, nurses are responsible for medication administration, pressure injury prevention, patient identity verification, and blood transfusion management [2,4]. As the largest group in the healthcare workforce, nurses spend more time with patients than any other professional group, placing them at the heart of patient safety efforts. To support this role, hospitals provide resources and training aligned with accreditation standards and focused on safe clinical practice [5].

Analysis of existing domestic instruments for measuring patient safety nursing activities has revealed considerable variations in their domains and composition. Park's [6] instrument comprises 72 items across 9 domains, including medication safety, fall prevention, and infection control, while Han and Jung's [7] instrument consists of 32 items across 8 domains including patient identification, communication, and presurgical/procedural patient safety. Park's [8] instrument consists of 24 items across 6 domains including patient identification, communication, and surgical safety, demonstrating significant differences in scope and content. Among the 11 core patient safety domains outlined by the Korea Institute for Healthcare Accreditation (KOIHA), several areas such as physical restraint management, blood transfusion management, and pressure ulcer prevention are omitted or addressed limitedly in existing instruments, resulting in insufficient alignment with accreditation standards. These variations limit research comparability and constrain accurate measurement of patient safety nursing activities in clinical settings. Therefore, comprehensive and standardized measurement instruments that align with accreditation standards are needed for general hospitals.

General hospitals are complex medical environments with a high proportion of critically ill patients and elevated risk of patient safety incidents. As a result, nurses' patient safety nursing activities play a more important role in ensuring patient safety. Moreover, general hospitals are the main target institutions for healthcare facility evaluation and accreditation, where patient safety nursing activities according to accreditation standards are practically applied. Therefore, this study aims to identify more practical aspects of patient safety nursing activities among nurses in general hospitals.

Perceptions of patient safety culture refer to how healthcare professionals understand, value, and engage with institutional safety policies and practices. A positive safety culture promotes open communication, effective teamwork, and proactive risk management [9]. Prior research has shown that nurses who perceive a stronger patient safety culture tend to engage more actively in patient safety nursing activities [10], and has identified safety culture as a significant predictor of patient safety nursing activities [11].

Patient safety knowledge is a fundamental requirement for all healthcare organization members, as it helps prevent patient harm. Research has demonstrated that patient safety knowledge and perception are key factors influencing the development of a safety culture and the implementation of safe practices within hospitals [12]. Nurses with higher patient safety knowledge levels tend to show greater engagement in patient safety nursing activities [13], and this knowledge has been identified as a major contributor to clinical performance [14]. In this context, nurses’ knowledge, attitudes, and skills are essential for providing safe care and minimizing the risk of medical errors [15].

Previous studies have reported that various individual and organizational factors—including perceptions of patient safety culture [16], communication satisfaction [15], workplace spirituality, organizational citizenship behavior, and awareness of patient care management [10]—are related to patient safety nursing activities that promote patient safety. However, most studies have examined safety culture perception and safety knowledge separately, and few have analyzed them together. Based on theoretical foundations and prior empirical research, this study identified nurses’ perceptions of patient safety culture and their patient safety knowledge as key factors influencing patient safety nursing activities. By analyzing these variables among general hospital nurses, this study sought to provide practical evidence to support efforts to improve patient safety.

This study examined the relationship between nurses' perceptions of patient safety culture, their patient safety knowledge, and their performance of patient safety nursing activities. The mean score for patient safety culture perceptions among nurses in the study hospitals was 3.34 out of 5, which is similar to previous findings by Kim and Lee (3.39) [15] and Nam and Lim (3.31) [25]. These findings suggest that nurses' perceptions of patient safety culture in the participating hospitals were at a moderate level, consistent with findings from similar hospital settings in previous studies. Because patient safety culture is formed through continuous awareness and practice by all members of an organization, repeated and systematic education is essential rather than short-term interventions. Accordingly, the Korean Accreditation Board of Nursing Education has designated patient safety as a core learning outcome in its fourth-cycle standards, thereby promoting its inclusion in nursing curricula [26]. Among the various domains, nurses rated frontline leadership highest, which is consistent with prior studies [27], suggesting that direct supervisors play a key role in shaping safety culture by supporting safe practices and fostering team involvement. In contrast, perceptions of the overall work environment and hospital-wide systems were relatively low, which aligns with earlier research indicating that organizational factors significantly influence care safety [28].

The average patient safety knowledge score was 3.72, which is consistent with findings from studies of general and university hospital nurses [29, 30]. Variations in scores may reflect differences in institutional safety education. Nurses in specialized hospitals scored slightly higher, likely due to more intensive or targeted training. International studies support this trend; for example, Shahrokhi et al. [31] reported that 49% of tertiary hospital nurses had sufficient knowledge, with differences identified according to age, education, and experience. These findings suggest that individual competence and institutional support—such as education systems and infrastructure—influence patient safety knowledge. Ongoing, context-specific training is necessary to effectively translate this knowledge into practice.

The mean score for patient safety nursing activities among general hospital nurses was 4.75, which is comparable to previous reports of 4.68 among nurses in integrated nursing care and general wards [5,25]. This similarity suggests that strengthened accreditation standards and increased institutional focus on patient safety may have contributed to this high performance. Among the subdomains, blood transfusion scored highest—consistent with earlier studies [25,32]—possibly reflecting its highrisk nature and strict oversight. In contrast, interprofessional communication received the lowest rating, highlighting ongoing challenges in teambased collaboration. Communication tools like SBAR (Situation-Background-Assessment-Recommendation) have been shown to improve clarity and teamwork [33] and are now commonly included in training programs, underscoring the need for continued education in this area.

However, these performance findings, must be interpreted within the methodological context of this study. This study employed Son et al.'s [5] comprehensive 96-item patient safety nursing activities instrument, which was specifically designed to reflect all 11 core domains established by the Korea Institute for Healthcare Accreditation (KOIHA). Unlike existing domestic instruments that often omitted critical safety areas such as physical restraint management and blood transfusion protocols, this tool enables standardized assessment across all required clinical activities. The observed high performance level (4.75±0.34) may therefore reflect both the comprehensive measurement approach and the actual safety competency of general hospital nurses when evaluated against accreditation-aligned criteria. This methodological approach enhanced the standardization of patient safety nursing activities measurement in Korea and improved research comparability with studies utilizing similar frameworks.

Beyond these methodological considerations, patient safety nursing activities also varied according to demographic characteristics. Nurses aged 35 years and above demonstrated significantly higher performance than those aged 25–29 years, consistent with earlier studies [11,34]; this likely reflects the influence of clinical experience, familiarity with hospital protocols, and increased professional confidence. Similarly, married nurses tended to perform better, possibly due to the greater career stability that often accompanies age. These findings indicate that experience, emotional maturity, and learning through practice are key to developing safety-related behaviors. Education programs should account for nurses’ experience levels and provide stepwise training for younger nurses to gradually build clinical skills.

In this study, patient safety knowledge emerged as the sole significant predictor of patient safety nursing activities, accounting for 17% of the variance. This finding aligns with previous research indicating that patient safety knowledge promotes safer nursing behavior [29,35], underscoring the need for ongoing patient safety education. Nonetheless, the modest explanatory power suggests that additional factors influence safety practices. Kim et al. [36] identified additional elements—experience, hospital size, leadership, ward environment, and communication systems—that affect safety practices, with subdomains such as communication, supervisor support, and hospital conditions exerting particular influence. Together, these results indicate that enhancing patient safety nursing activities requires both individual patient safety knowledge and organizational support.

This study's finding that patient safety knowledge was the sole significant predictor of patient safety nursing activities differs from previous research [9, 35,37] and requires careful interpretation.

The lack of direct effect from patient safety culture perceptions may be attributed to organizational mediating factors. Wu and Lee [38] demonstrated that managerial leadership fully mediated the relationship between safety culture and safety outcomes, while Lee and Jang [39] found that communication quality explained 59% of variance in patient safety culture. Additionally, Tran et al. [40] identified indirect pathways where job-related factors influenced safety climate through emotional exhaustion and teamwork. These findings suggest that effective leadership and communication systems serve as necessary mediators for translating individual safety culture perceptions into actual nursing activities.

In contrast, the significance of patient safety knowledge reflects the characteristic that practical, specific competencies can directly drive behavioral change more effectively than perceptions or attitudes. This aligns with Shahrokhi et al. [31], who found that specific patient safety knowledge directly influences actual safety behaviors. Unlike abstract cultural perceptions, concrete knowledge provides nurses with actionable guidelines that can be immediately applied in clinical practice.

The importance of organizational factors over individual perceptions is further supported by Han and Jung's [7] findings that organizational health shows strong correlations with both patient safety culture (r=.52, p<.001) and patient safety nursing activities (r=.31, p<.001). This suggests that creating supportive organizational environments may be more crucial for promoting safe nursing practices than focusing solely on individual awareness of safety culture. Future research should examine how these mediating factors operate in the relationship between safety culture perceptions and nursing activities in general hospital settings.

This study has several limitations. First, the cross-sectional design limits causal inference between variables. Second, data were collected from only two general hospitals in a single region, which may limit generalizability to other hospital types and geographic areas. Third, self-reported measures may introduce social desirability bias and may not fully reflect actual performance. Fourth, important organizational variables such as hospital size, staffing ratios, and leadership effectiveness were not analyzed. Finally, while patient safety culture perceptions were not directly predictive, potential mediating factors such as communication quality and organizational climate were not examined, which may explain the non-significant relationship. Future studies should employ longitudinal designs and include organizational mediating variables to better understand these complex relationships.

Despite these limitations, our findings highlight the critical role of patient safety knowledge in effective nursing practice and provide actionable guidance for healthcare organizations. For nursing practice, these findings suggest implementing structured patient safety knowledge education programs with competency-based assessments, regular safety training integrated throughout continuing education, and development of unit-based safety champions to bridge knowledge and practice gaps. Healthcare organizations should prioritize systematic educational approaches while strengthening organizational mediating factors such as leadership support and communication systems. The comprehensive measurement approach using KOIHA-aligned instruments demonstrated its value for accurate performance assessment and continuous quality improvement. The standardized measurement framework established in this study can serve as a foundation for benchmarking and monitoring patient safety performance across healthcare institutions. Future research should employ longitudinal designs to establish causal relationships, utilize mixed-methods approaches to understand the knowledge-practice relationship mechanisms, and include multi-level analyses examining individual and organizational factors simultaneously. Additionally, intervention studies testing specific educational approaches are needed to translate these findings into practice.

This study examined the effects of patient safety culture perceptions and patient safety knowledge on patient safety nursing activities among nurses in general hospitals. The results demonstrated that patient safety knowledge was a factor that significantly influenced nurses' patient safety nursing activities, while patient safety culture perceptions were correlated but were not identified as independent influencing factors.

These results provide evidence-based guidance for healthcare managers and educators. Specifically, hospitals should prioritize: (1) systematic patient safety knowledge education programs with regular competency assessments, (2) structured mentorship programs, (3) development of organizational mediating factors such as leadership support and communication systems, and (4) use of standardized, comprehensive assessment tools aligned with accreditation standards for continuous monitoring.

However, this study was conducted in a limited number of general hospitals in a single region and has limitations in that it may not fully reflect organizational structure or environmental factors. Future studies should include a variety of structural factors, such as organizational culture, management support, and workforce composition, as well as conduct multicenter comparative studies to increase explanatory power. Additionally, exploratory studies of mediators and moderators of the relationship between patient safety culture perceptions and patient safety nursing activities are warranted.