Health care leaders have a critical role in establishing and supporting a robust culture of safety. This report analyzed the environment of care at one Veterans’ Affairs hospital that perpetuated poor psychological safety, thereby reducing improvement opportunities. The examination concluded that the responsibility for the situation sat squarely with organizational leadership, who dismissed staff concerns, failed to examine factors contributing to problems, and fostered an unsafe deference to hierarchy. Recommendations for improvement focus on improving use of human resources strategies to generate needed change.