hi,caliotter,i really agree on your post.i hve quite similar experience. in the morning, i hve to check blood sugar level to a resident who is for insulin.i found in the tray an insulin syringe with medication on it,we had only one patient on insulin on that time and the dose in the syringe was the same amount of resident's 6pm dose.i checked the MAR sheet, and found out,it was my line manager who was on duty and the last person who gave and signed the last dose.thanks God nothing happened to the resident whole shift.It was difficult for me to asked her for not making her feel being demoralized and the consequences .But i did.