PONE-D-22-35534Comparison of medical students' perceptions of patient safety: Focusing on siulation training using a high-fidelity simulatorPLOS ONE

Dear Dr. Jung,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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This study is an interesting and important paper on patient safety in medical education. However, in the introduction more background on the simulation used in safety courses should be given.

In the method, there should be more detailed description of the research group and the setting. Both reviewers mentioned that there is more elaboration needed on how you educate the students, what ‘s the content of their training. The scenarios run in the sessions and how they were implemented and what were the main points of debriefing should be explained more clearly. According to Reviewer 1; the questionnaire has no validation. The formation process of the questionnaire details should be given more explicitly.

The results should be clarified and the discuss should be enriched with relevant related studies.

==============================

Please submit your revised manuscript by Jun 12 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ipek Gonullu, M.D., Ph.D.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Respected Authors,

Thank you for considering such a vital topic. However, I do encourage further work on the manuscript.

First, I would like more background on the simulation used in safety courses. We know it enables practice in a safe environment, but I would like you to Focus on the immediate connection with your text.

Not explicit, the introduction is too long when a whole manuscript is considered.

Additionally, there is no detailed description of the research group or the setting; the results are mixed with the methodology.

We need more details on the scenarios run in the sessions and how they were implemented- all eight students a once-at-one scenario. I would not describe debriefing as feedback; it has a broader function- please list which debriefing method was used and what were the main points of debriefing. We have no doubts that a qualified person runs it in medical school—more details on the process. To few details are given on the questionnaires used.

The results are very basic, it is a very simple pre-post comparison. We have no validation of the questionnaire. Please re-think the calculations and how they apply to the clinical actions. There may be more data to work on.

Conclusions are just repetitions of the results.

Therefore, I cannot recommend the text for publication in its current form.

Reviewer #2: Many thanks for the authors to tackle this important subject (patient safety education), please find my comments to improve the manuscript

1. In general an English language editing is required to decrease the word count in certain parts

2. Introduction: no need for too much details on benefit of simulation education

3. Method: how you educate the students , elaborate more on the content of their training , you only mentioned the process

4. Results: a. No 4 and 15 , 19 in table 1 the same data reading noticed in pre and post survey but the p value show highly significant????

b. the table headings is it P value or t value

c. Total in the table is not clear is it the sum , average??? you need to clarify more

d. No need to repeat the result of the table in the written text just concentrate on the main changes

In Discussion it is not clear weather your students have repeated training or it was single training opportunity (2nd paragraph)

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Reviewer #1: No

Reviewer #2: No

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PONE-D-22-35534R1Comparison of medical students' perceptions of patient safety: Focusing on simulation training using a high-fidelity simulatorPLOS ONE

Dear Dr. Jung,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 24 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ipek Gonullu, M.D., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

Although this is an interesting study on an important topic, it needs more improvement. In the introduction there should be clearer delineation of the need for this work and how this study would contribute to the literature.

In the method, there is more elaboration needed on how you educate the students, what ‘s the content of their training. As Figure 1 and 2 are not enough, the scenarios run in the sessions and how they were implemented and what were the main points of debriefing should be explained more clearly. Besides the questionnaire used for the study has no validation. Simple pre-post comparison results may be assessed/calculated by re-thinking how they apply to the clinical actions.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

Reviewer #4: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

Reviewer #4: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

Reviewer #4: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: They have addressed all the concerned issues, they have shortened the introduction, revised the statistical analysis, I think, it should be accepted

Reviewer #4: This is a Kirkptarick Level 1, pre-post survey design study of 40 medical students at a single medical school during a single pediatric rotation undergoing a specific simulation-based education experience. As such, the findings will be necessarily limited in scope. Since this is a small and new intervention being trialed, it may be better to think of this as a pilot program/QI project. Especially as the authors cannot control for other educational interventions occurring during the 4 weeks of the clerkship that may have affected knowledge, skills, and attitudes beyond their simulation scenarios, which further limits the ability to conclude that their specific intervention is responsible for the results.

Specific comments:

Having read the previous reviewer comments, I feel that the introduction remains too long and is not germane to the study itself. The introduction should focus on simulation safety education literature and how this study would contribute to the literature/answer an unanswered question. Since simulation education like this has been provided for many, as has patient safety education, there needs to be a clearer delineation of the need for this work. Page 4, lines 73-75 are repetitive of a point made in the preceding paragraph; one or the other can be eliminated. Apropos to better delineation of the need for the study, since this is a topic that has been explored before and has already been shown in Korea in nursing students, why should simulation education affect on medical students be different?

Materials and Methods:

Both Figures 1 and 2 do not appear in the copy of the manuscript that I am able to access. Their legends do, as does the entirety of Table 1, so I am unable to state specifically anything regarding their effectiveness/appropriateness. In the Design and Setting, very little demographic data is presented (28 males, 12 females) -- what else is known about the survey/study participants? Ages? Experiences (either work, research, or clinical) that may have affected their answers? More information is needed.

Under Simulation Program Setting (page 5, lines 113-4), the statement is made that debriefing was provided to provide feedback on the learners' knowledge, skills, and attitude. This is not enough information, and does not address adequat5ely previous reviewer concerns. was a specific tool utilized to ensure that all the objectives of the simulation were achieved? did the students switch roles (they were paired up, but it does not say if they had different roles and then did the scenario again after switching roles)?

Results and Disussion:

Of the 30 questions, only 6 had statistically signfiicant changes in responses, 3 in attitude and 3 in self-efficacy. Average score across 24 attitude items did not change. Average score across the 6 self-efficacy items did, which was the predominant driver of the overall average over 30 questions of a statistically significant average score. I find the limited number of items that showed change less convincing of the effectiveness of the education than the authors do, and feel that the conclusions are too broad compared to the limited effects demonstrated in the results section.

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

Reviewer #4: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-22-35534R2Comparison of medical students' perceptions of patient safety: Focusing on simulation training using a high-fidelity simulatorPLOS ONE

Dear Dr. Jung,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

I thank the authors for addressing the reviewers’ comments. However, it needs more improvement about the necessity of this study in terms of patient safety and simulation training together.

The simulation program was not described clearly (development, the content of their training, scenarios, debriefing ,…)

Please submit your revised manuscript by Mar 14 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ipek Gonullu, M.D., Ph.D.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #5: (No Response)

Reviewer #6: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #5: Partly

Reviewer #6: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #5: Yes

Reviewer #6: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #5: Yes

Reviewer #6: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #5: Yes

Reviewer #6: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #5: The manuscript seems to have been revised a lot, according to previous reviewer comments. However, in my opinion, to reflect their comments, further revision would be necessary. First, the necessity of this study should be mentioned in terms of patient safety and simulating training together. In the introduction, the authors seem to be dealing with the necessity of this study in terms of patient safety and simulating training separately. This discrepancy weakens the necessity of this study. 

Second, Figure 2 does not reflect the process of the simulation program’. It looks like the process of this study. Under the title'simulation program setting’, the authors do not carefully use the terms'simulation program' and'study' differently, which confuses readers about the study between the traning programs. Fig. 2 should be included under the title “Design and Setting."

Third, along with the Fig. 2 problem, the study design should be more detailed to determine, when the survey was taken, whether there was no difference in simulation experience due to the rotation experience (since for most medical schools in Korea, students’ previous experiences are different due to the rotation assignment). Furthermore, authors should describe the development of simulation programs, whether they adopt previous simulation programs based upon previous studies, etc. It is hard to compare the efficacy of the program if there are any reference points.

Reviewer #6: I thought the previous version was acceptable and the current additional revision is acceptable. At some point, the data need to be made available to the readers for scrutiny.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #5: No

Reviewer #6: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Comparison of medical students' perceptions of patient safety: Focusing on simulation training using a high-fidelity simulator

PONE-D-22-35534R3

Dear Dr. Jung,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ipek Gonullu, M.D., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #4: Partly

Reviewer #5: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: Yes

Reviewer #5: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #4: No

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #4: Yes

Reviewer #5: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: The authors have addressed my previously stated concerns. Lines 42 and 43 in the introduction (page 2 of the PDF) are duplicative from the paragraph before and can be deleted. The introduction still reads too long and could be more concise to get to the study itself faster, but these are minor quibbles.

Reviewer #5: The author revised the manuscript according to the comments sufficiently. There is no further suggestions.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #4: No

Reviewer #5: No

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