**4. Clinical Futile Cycles and the traditional hierarchical referral model of care**

The term "Futile Cycle" is a term used in cell biology and biochemistry to explain the conversion of one substance to another and back to the original substance by two always on enzymatic pathways. However, despite the enzymatic activity and energy utilisation there is no net output or gain from this energy consuming and active process. This is exactly what we see with hospital patient adverse events, and in particular the deteriorating patient; a lot of clinical activity, none of which effectively alters the trajectory of the patient in the downward spiral to the HAE. The clinical activity occurs in a traditional hierarchal referral model of care that by its very nature is often either unresponsive or slowly responsive and where the exhaustive policy and procedures are often ignored.

In the hospital, the "Clinical Futile Cycle" usually starts with the most junior level of the "traditional hierarchical referral model of care," at the bedside with the interaction between the junior nurse and the patient (**Figure 5**). With a clinical abnormality, be it an observation, a wrong drug order, or a procedural failure, the junior nurse must make a decision as to the significance of the abnormality and the importance of

**Figure 5.** *Clinical Futile Cycles [23, 24].*
