Beyond Blame: Building High Reliability Organizations
Episode Title: Blame Culture vs. Just Culture: How High-Reliability Organizations Learn from Mistakes
Host: Scott Arrieta, CEO of Unity & Company
Guest: Dr. Ur Barzell, Organizational Change Expert & Vanderbilt Faculty
Episode Summary:
In this compelling episode, Scott Arrieta sits down with Dr. Ur Barzell—accomplished learning strategist, change management practitioner, and faculty member at Vanderbilt University—to explore the powerful concept of high-reliability organizations (HROs) and what they can teach us about leadership, systems thinking, and human error.
Dr. Barzell recounts the tragic real-life story of nurse RaDonda Vaught and the systemic failures that led to a patient's death—and her subsequent criminal prosecution. What unfolds is not just a conversation about a medical error, but a deep dive into the difference between blame culture and just culture, and how our tendency to punish individuals often blinds us to the systems-level issues that truly need fixing.
Drawing on case studies from healthcare, aviation, military, and even amusement parks, Dr. Barzell introduces powerful tools like the Swiss Cheese Model and crew resource management—models that show how organizations can minimize risk by addressing system vulnerabilities instead of scapegoating individuals.
From glove changes in operating rooms to psychological safety in team dynamics, this episode shines a light on the human cost of silence—and why creating safe environments for speaking up is essential not only to organizational health, but to saving lives.
🔑 Key Themes:
The case of RaDonda Vaught and what it reveals about systemic failure
How blame culture prevents learning and improvement
High-Reliability Organizations (HROs): what they are and why they matter
The Swiss Cheese Model: understanding layers of defense and failure
Psychological safety and Amy Edmondson’s groundbreaking research
What leaders can do to design safer, more responsive systems
Breaking down hierarchy to encourage truth-telling and accountability
👤 About Dr. Ur Barzell:
Dr. Barzell is a certified Prosci change management practitioner and expert in high-reliability systems. He has 18+ years of experience leading organizational transformation in healthcare, government, and defense. As a faculty member at Vanderbilt University's Peabody College, he teaches Organizational Change Management and Strategic HR, shaping the next generation of systems thinkers and change leaders.
📧 Contact Dr. Barzell: urbarzell@gmail.com
🔗 Resources Mentioned:
The Swiss Cheese Model by James Reason
Psychological Safety research by Dr. Amy Edmondson
Case study: The prosecution of nurse RaDonda Vaught
Crew Resource Management (CRM) in aviation safety
📣 Connect with Unity & Company:
Unity & Company partners with leading brands to unify leadership teams and catalyze cultural transformation. If you’re interested in creating a high-trust, high-performance organization, reach out to us at:
📧 info@unityandcompany.com
🌐 unityandcompany.com
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