I need an IRAC (Issue, Rule, Analysis, Conclusion) for this scenario:

Mary visited her twin sister Cecilia, in the hospital where she had recently undergone surgery. During the visit and in full view of Mary, a nurse erroneously gave her Dilaudid instead of Dilantin, sending Cecilia into an epileptic shock, resulting in Cecilia's death. Mary was horrified by the incident, she developed insomnia, nightmares, and depression, which required psychiatric treatment.