**1. Introduction**

When unexpected clinical deterioration results in patient harm (death or permanent disability), healthcare in an attempt to learn from its mistakes, uses Quality Improvement tools from other industries, principally Root Cause Analysis (RCA). RCA methodology takes a structured template of criteria that is applied objectively to the timeframe of the adverse event in question. The outcome of this process is a set of learnings for practice improvement. The purpose of this article is not to detract from

the process of RCA, rather to question why all too often despite, a RCA, the same mistakes are repeated often again and again. Indeed, overall, the incidence and outcomes from hospital adverse events (HAE), has not improved over the last two decades [1–6]. This is despite widespread recognition of the problem, extensive epidemiological research, and billions of dollars of investment into quality and safety programs [2, 3].

Clinical Futile Cycles is defined as clinical activity that has no nett benefit to the patient. Across all spheres of medical practice clinical activity is undertaken with no actual benefit to the patient but also that does no harm apart from cost. In the case of a patient's condition deteriorating clinical activity is needed to cure or at least improve the clinical situation. In the critically unstable patient, failure to improve the patient condition is equivalent to deterioration, due to the underlying principles of pathophysiology. Cellular homeostasis is dependent on adequate delivery of oxygen to mitochondria to sustain aerobic metabolism. Anaerobic metabolism due to blood loss, hypoxia, sepsis, cardiopulmonary pathology has to be reversed or the cell, and then an organ and eventually the body will die. As such it is imperative that in this type of clinical situation the clinical activity is productive in the restoration of homeostasis, not futile, to prevent the downward spiral to death or permanent disability.

In this article, the case for the examination of HAE, through a process of looking for and then examining the Clinical Futile Cycles that inevitably occur throughout patient deterioration is made [7, 8]. In doing so, the pandoras box of what really goes on at the interface between the deteriorating patient, the individual frontline health care workers, and finally and just as importantly, the socio, cultural, political nature of involved health care system and or hospital, is opened. Thus, the learnings are focused on changes that are needed to create productive clinical activity that improves patient outcomes. Finally using this model, some fundamental reforms for the prevention of these adverse events are proposed.
