This case study examines how analyzing inaccurate referrals can provide key insights into managing change. The author analyzes what went wrong in an attempt to identify opportunities for an Access Services department to consider how it might adapt to constant change. She wishes to show how the nature of change today demands that one pay particularly close attention to occurrences that might otherwise be handled more routinely. Challenges in six operational areas are explored along with suggestions for alternate ways to respond. (Contains 1 figure.)