In this study, we identified the top ten research priorities focused on patient safety and the hospital RRS. Hospital healthcare professionals were actively engaged as key stakeholders. The top-ranked research priority questions demonstrate the need to evaluate and explore how simulation, regular training and case reviews led by the RRT can improve the competence, confidence, and collaboration of healthcare professionals in critical situations, reflecting a growing recognition of the importance of professional collaboration in managing complex and critical patient situations effectively. This is consistent with findings from previous research studies showing that systematic team training can be associated with better collaboration and safer patient care pathways [31, 32]. However, these findings need to be further explored.

Our top ten research priorities address universal patient safety challenges related to limited resources, communication barriers, and vulnerable transitions between levels of care, and emphasise operationalising hospital patient safety. In particular, they focus on tangible, RRT-led capability-building and ethical challenges, including regular training and case reviews. These priorities strengthen healthcare professionals’ competence, confidence, and collaboration in recognising and managing deterioration across wards or departments and at the clinician-patient interface, providing clear targets for further research and improvement. Across these areas, tools and strategies to measure, monitor, and improve patient safety remain limited, underscoring the broad applicability of our findings, particularly for diagnostic processes and care transitions [33]. The emphasis on communication, escalation, and data quality is also relevant in primary care, supporting earlier detection, timely escalation, and safer handovers between community and hospital health services.

One priority called for evidence to bridge the gap between hospital and community healthcare services, emphasising the importance of continuity of care and transferable patient safety practices across settings. For comparison, the JLA PSP on patient safety in primary care by Morris et al. [5] highlighted similar themes around communication, transition of care and improving understanding of patient whose safety is vulnerable. Conducted on a broader scale and directly engaging patients, carers, and community stakeholders, their PSP highlighted gaps affecting underserved groups. In contrast, our hospital’s RRS top ten priorities center on operational delivery of safety. PSP stakeholders prioritised evidence on RRT-led training and case review, explicit escalation thresholds and protocols, team composition and response time for patient deterioration, measurements and monitoring, and the transfer of hospital practices to community services. These differences reflect scope and stakeholder composition. Our top ten priorities are based on PSP stakeholder’s experiences from hospital RRS and patient safety work in a Norwegian setting with strong representation of system and service-delivery concerns, whereas Morris et al. [5] engaged a broader primary-care community of patients and carers. The primary care PSP placed greater weight on patient-and community-facing needs, equity for vulnerable populations, and continuity and understanding of safety in an everyday primary care context, elevating priorities related to access, vulnerability, and whole-person care.

It is notable that ethical research questions rank highly in our list of research priorities, underscoring how closely these priorities mirror daily challenges experienced in hospital practice. The second-ranked research priority brings attention to the ethical complexities in decision-making and end-of-life care, indicating an urgent need to investigate how the hospital’s RRT can support healthcare professionals in navigating these morally and emotionally challenging situations, and ensuring patients-centred care. While existing studies provide valuable insights, significant gaps persist in end-of-life-care, especially around cultural competence, standardised educational programs and nurses’ contributions regarding their role in hospital RRS and patient safety improvement [8, 12, 34]. By focusing on priorities identified by frontline hospital healthcare professionals, our work ensures actionable and context-sensitive patient-safety findings, consistent with prior studies showing that co-produced, stakeholder-led priority setting improves relevance and uptake in hospital settings [13, 24, 35, 36].

Our modified JLA PSP process demonstrates how JLA principles can be adapted for smaller-scale projects and applied across patient safety contexts [37, 38]. This pragmatic adaptation addresses a gap in the literature and emphasises user involvement, with stakeholder engagement sustained beyond project completion, demonstrating a robust, collaborative process. Our modified JLA PSP process facilitated broad involvement and collaboration, linking research more closely to clinical practice by engaging stakeholders with diverse roles and hands-on experience in hospital RRS research prioritisation. In doing so, it brought research closer to practice by foregrounding experiential knowledge and ensuring that the priorities reflected real-world needs [18]. User participation in health research parallels the democratisation of the health service and rising expectations for patient and public involvement [38]. To reduce research waste, questions must be relevant to users, grounded in evidence gaps identified from comprehensive evidence syntheses, and not already answered [22]. While PSPs often include multiple participants representing different user groups, including former patients and relatives [5, 35], this study focused on hospital RRS and health professionals with hands-on experience, managing deteriorating patients in hospital settings, and senior leaders, ensuring a broad range of expertise. Despite including a former patient as a stakeholder, the modified JLA PSP may still have deprioritised patients’ top three priorities, as excluding patients and carers may have led to missed evidence gaps particularly relevant to them, for example, communication with families when patients deteriorate. Stakeholder feedback indicated that the modified JLA PSP was feasible and important to both the former patient and the healthcare professionals, who valued the opportunity to shape research priorities directly relevant to their daily practice. For many hospital healthcare professionals, participation in the modified JLA PSP was a novel approach which was well received, and participants were motivated to be involved in similar work in the future.

Using a modified JLA PSP secured data availability and methodological robustness and highlighted the need to strengthen RRS knowledge and experience. Early scoping of RRS enabled an efficient process, guided by a steering group and informed by an expert panel and project team, integrating professional and user perspectives to generate actionable RRS research priorities. We recognise potential trade-offs in identifying research needs through a modified JLA process. Because priorities reflect the context-bound perspectives of those involved, emergent or minority views may be under-represented, and group dynamics can privilege dominant voices. We mitigated these risks through a transparent, five-stage, participant-led, modified JLA PSP process. This modified JLA PSP can be adapted for small-scale contexts to identify actionable patient safety research priorities for RRSs [24, 37, 38].

By focusing on stakeholders’ priorities, we propose a targeted agenda to advance patient safety and strengthen hospital RRS improvements. Achieving this requires collaboration among healthcare professionals, patients, policymakers, and researchers [10, 38, 39]. It also underscores the importance of well-defined roles, adequate resources, and training to meet increasing care demands [12, 13, 39]. This work addresses persistent evidence gaps on how hospital RRS implementation shapes interprofessional practice, as highlighted by Allen et al. [14] and aligns with national calls from health authorities, hospital leaders, and clinicians for systematic evaluations before introducing new hospital technologies [37]. Engaging healthcare professionals with diverse experience revealed evidence gaps, most notably the effect of hospital RRT activation thresholds on patient outcomes, highlighting areas for further exploration [18, 39, 40].

A strength in the hospital prioritisation exercise included the first author’s established networks and field familiarity. This enabled efficient recruitment of user participants to the steering group and expert panel and broad representation of healthcare professionals. The organisational anchoring and the hospital’s sense of ownership enhanced the project’s relevance and integration within the organisation. User representation included both healthcare professionals (experts in their field) and members of the Hospital User Committee (service users who could act as experts), providing a comprehensive perspective. Familiarity with patient safety work ensured that priorities reflected operational needs, workflows and constraints, offering practice-grounded insight that is directly applicable in a hospital setting. Existing relationships expedited coordination across wards and departments. While this could pose a challenge if professionals felt obligated to participate, it also provided the strength of knowing how to effectively engage with them.

However, proximity to the field and existing relationships may have created a sense of obligation to participate, introducing potential bias and a risk of blind spots. Consistent with JLA principles, meaningful user involvement, combining professional expertise with service-user perspectives, linked research prioritisation closely to clinical practice. Including healthcare professionals as user representatives, while valuable, can skew perspectives toward professional interests unless balanced by broader service-user input. Hospital leadership may hold interests that differ from those of the researcher, underscoring the need for critical reflection on influence and decision-making. The first author’s pre-understanding, hypotheses, and professional and theoretical perspectives on patient safety, were advantageous for navigating the setting but may have limited recognition of new insights [41]. Strong organisational anchoring may reduce transferability to contexts with different structures, cultures, or stakeholder compositions.