Last year, Michelle fell off a ladder while fixing some Christmas lights that had come loose outside her suburban Virginia home. She landed awkwardly on her leg, and the pain was intense. She called her doctor. It was Dec. 23, and his office had closed at noon for the holiday. In a phone call, he told her to go to an urgent care clinic. The clinic took X-rays and sent her home.

Two minutes after her doctor's office reopened four days later, she got a dramatic call from him: Her leg was badly broken and she needed emergency surgery.

At the hospital, Michelle refused to let the first available surgeon operate on her. She had previously had a bad experience with an unfamiliar surgeon and was taking no chances. She ended up parked on a gurney in a hallway in the emergency room for almost 10 hours while she waited for a surgeon she knew and trusted to be free to see her.

She reported that she experienced three different problems with the care she received. In two of those cases, she could have been seriously injured if she hadn't been alert and cautious enough to speak up.

The first problem arose when a nurse came to insert a urinary catheter. Despite Michelle's frantic protests, the nurse made liberal use of an iodine solution to cleanse the area thoroughly. Michelle is allergic to iodine solutions used on the skin. Within half an hour, Michelle was in agony with severe pain, burning and inflammation.

For two hours, she begged for help and none was forthcoming. Finally, a technician who came to draw blood handed her some baby wipes. Hiding under the sheet in the hallway, she attempted to use these to remove as much of the iodine solution as possible, but the damage was already done. For the next month, she suffered from incontinence as a result of the severe inflammation and irritation.

Even more disturbing was the second experience. Five or six hours after Michelle arrived, a nurse walked up to her gurney. She flipped back the sheet to uncover Michelle's right leg. She handed Michelle an uncapped marker, and said, "Sign your name on your leg."

Cautious about blindly following orders, Michelle asked, "Why?"

The nurse said impatiently, "It's so the surgeon will know which leg to operate on."

Michelle blanched. "But my left leg is the one that's broken!"

The nurse did not look at Michelle's legs at all. She looked at her chart.

"Oh, so it is," she said, and covered Michelle's right leg, then uncovered the left one. "Sign your name." Michelle was stupefied. The nurse did not seem sorry or even embarrassed, and she didn't apologize.

The third problem surfaced when a nurse came to tell Michelle that she was going to take her upstairs so that she could be prepped for surgery. She was going to start an IV drip with an antibiotic in it. The nurse glanced at Michelle's chart, and commented that Michelle didn't have any allergies.

The hospital had a policy of putting a red band around the right wrist of any patient with an allergy. The band identifies the substance to which the patient was allergic. Hospital employees were always supposed to check the patient's right wrist before administering any drugs.

Michelle held up her right hand. Three red bands circled her wrist: one for iodine, one for morphine and one for penicillin. The antibiotic that the nurse was planning to give her is not supposed to be given to patients with penicillin allergies. Many of the people who are allergic to penicillin are allergic to the other drug as well. The nurse was embarrassed and apologetic that she had not checked before making a dangerous assumption.

Michelle reports in exasperation that she was unusually alert because of yet another problem preceding these: Early in her stay they had tried to set up a morphine IV drip. Because she is allergic to morphine, her hand had swollen to twice its normal size. They had removed the IV line and hadn't placed another one in. As a result, she had no sedatives of any kind in her system. Usually, a patient in her condition would have been heavily sedated for pain relief, and very well might not have caught the errors that put her at risk.

Michelle's experience highlights three very important points about errors in emergency rooms. First, health professionals such as doctors and nurses know that these errors are common and may even have put processes in place to prevent them. Clearly, getting the patient to sign her name on the side of the body to be operated on is intended to prevent doctors from operating on the wrong side. Putting hard-to-miss wristbands on patients is intended to ensure that their allergies are noticed by everybody.

Second, the professionals can often defeat the safety features if they take shortcuts. Asking the patient to sign her name on the body part to be operated on is supposed to help prevent a serious error. Telling Michelle to sign her name on her leg without explaining why could have created a huge problem. But research suggests that health care professionals often believe that involving patients in their own care is unnecessary. As a result, from the nurse's perspective, this step was apparently just one more hoop to jump through. She was going through the motions but missed the point.

Third, patients need to be their own advocates in the ER (or bring someone with them who can be their advocate), and they need to be attentive. Questions to consider include:

1. What is the purpose of this action? Going along with activities without understanding their point can lead to big problems.
2. Is this test or treatment or procedure really intended for me? If you were not expecting it, ask to see the doctor's order.
3. Is there anything about me or my condition that would make this test or treatment a bad idea? The possibilities here include allergies, prior bad reactions to the same or similar actions, or other medical problems that increase the risks of this action.
4. What does it take to perform this action with the least possible risk for me? For example, have the doctors and nurses washed their hands? Is there a checklist to use to make sure that no steps are missed?

Paying attention to these issues can help you get the benefits of emergency care while avoiding some of the dangers.