Clinical Crossroads is a popular series in the Journal of the American Medical Association (JAMA) that highlights patient and provider perspectives in common clinical scenarios. This article discusses a patient who experienced delays in care due to a myriad of system failures in the ambulatory setting. The invited discussant explores the causes of these failures and discusses situational awareness, improved handoffs, and fostering a culture of safety. Emerging test management systems and critical test follow-up practices are key elements of proposed improvements. The fact that JAMA chose a clinical scenario focusing on systems failures mirrors past efforts in the Annals of Internal Medicine and the New England Journal of Medicine to spotlight patient safety—all noteworthy events for such high impact journals.