Transitions of care are a high-risk point for children and young people, particularly at hospital discharge where medicines information can be unclear, incomplete or difficult for families to use. This can lead to dosing errors, missed medicines, and avoidable harm once a child is back at home or in primary care. In paediatrics, this is often made more complex by weight-based dosing, unlicensed and special medicines, and the fact that parents or carers are responsible for giving medicines. This session will focus on what actually goes wrong at discharge and why. Using real examples from practice, we will look at common risk areas including discharge documentation, labelling, and communication across care settings. We will also share practical approaches to improving safety, including clearer discharge letters, better engagement with parents, and use of tools such as the Discharge Medicines Service, Medicines for Children and PADDINGToN. The session is designed to be relevant across sectors, with a focus on simple, realistic changes that can improve safety at the point of discharge.