A common theme in patient safety literature is the call to move beyond a culture of blame. Although more recent scholarship, especially within frameworks like just culture, has shifted toward emphasising accountability, a general presumption against blame remains widespread. I argue against this presumption in the context of external blame, that is, when patients or their advocates affected by errors blame healthcare professionals. My focus, in line with standard just culture literature, will be on cases where there is no clear intent to harm and where errors are primarily or largely due to systemic factors or shortcomings. I develop the argument in three steps. First, I aim to establish that forward-looking approaches to accountability (those concerned with learning, prevention, and system improvement) are necessary but insufficient. Second, we also need robust backward-looking approaches to accountability. Third, I claim that a constitutive element of such backward-looking accountability involves making space for external blame. Drawing on Miranda Fricker’s conception of communicative blame, I argue that accommodating patients’ or their advocates’ pull toward blaming healthcare practitioners in a backward-looking sense can enable important perlocutionary effects, namely, a change for the better in how healthcare is provided and received. I qualify this argument by noting that optimism about the constructive potential of such blame must be tempered by the risk of an unfair distribution of its burdens.