HSIB has identified a significant safety risk posed by the communication and transfer of information between secondary care, primary care and community pharmacy relating to medicines at the time of hospital discharge. A reference event was identified that resulted in a patient inadvertently receiving two anticoagulant medications at the same time, possibly causing an episode of gastrointestinal (digestive tract) bleeding. Increasingly, healthcare facilities in primary and secondary care are introducing digital solutions (electronic prescribing and medicines administration (ePMA) systems) to improve medicines safety. However, analysis of the reference event identified how ePMA systems can create their own risks – risks that will need to be addressed as these systems become more widespread. Other risk factors relating to prescribing and the discharge of the patient, including medicines reconciliation, availability of pharmacy services and weekend working, were identified during the investigation.