Per Minnesota Statute 214.10, I am filing a formal complaint against Dr.
Robert Tibesar. In prescribing a drug contraindicated for post-operative, non-opioid tolerant patients, Dr. Tibesar violated Minnesota Statute 147.091, subdivision 1, paragraphs "g" (incompetence), "k"
(unprofessional conduct), and "s" (prescribing practices) which the Minnesota Board of Medical Practice ("Board")
is clearly empowered to enforce. Additionally, per Minnesota Statute 214.103, I request a review of this case by a representative
of the attorney general's office.
At first glance, one might assume that the Board has
no jurisdiction in this case. However, Dr. Tibesar was
practicing medicine at Wright-Patterson Air Force Base in Dayton, Ohio under his Minnesota physician's license. The Air Force
requires a physician to have a license to practice medicine before he can be considered for employment. Therefore, the military
is the place of employment and Minnesota is the licensing authority. The military can only discipline as an employer and has
no jurisdiction in licensing matters.
If the military had not been the employer, Dr. Tibesar could have been charged with manslaughter in the second degree in Minnesota or criminal reckless
homicide in Ohio. Minnesota Statute 609.25 states that a person who causes the death of another by the person's culpable negligence
whereby the person creates an unreasonable risk and consciously takes chances of causing death or great bodily harm to another
is guilty of manslaughter in the second degree. Ohio Revised Code 2903.041 states (A) No person shall recklessly cause the
death of another or the unlawful termination of another's pregnancy, (B) Whoever violates this section is guilty of reckless
homicide, a felony of the third degree.
Tibesar had ready access to repeated warnings concerning the extreme risk of prescribing fentanyl transdermal patches
("fentanyl") and the consequences of administering fentanyl in absolute violation of its explicit directions for
use. Nevertheless, he proceeded with conscious indifference for the life and
safety of MSG Harold W. Kinamon, Jr. ("MSG Kinamon"). There was no intention to kill, but the doctor did not act
with the care and caution of a reasonable person in a similar circumstance. He did not follow the standards of practice for prescribing opioids. Furthermore,
Dr. Tibesar had a broad range of post-operative, non-opioid alternatives from
which to choose that did not pose life-threatening risks. Prescribing information states that fentanyl should not be the first
opioid medicine that is prescribed for pain.
According to a Pulitzer-winning series
that appeared in the Dayton Daily News in October 1997, state boards are hesitant to discipline physicians
because it is difficult to get patient records from the military. Therefore, I have enclosed information which proves Dr. Tibesar was the attending physician, and therefore was the one who prescribed
the 75 mcg/hr Duragesic® patch for MSG Kinamon's post-operative, acute pain. The autopsy indicates that death occurred
as a result of the toxic level of fentanyl in MSG Kinamon's system from the one 75 mcg/hr patch that was found on MSG Kinamon's
There is no doubt that MSG Kinamon's pain was caused by the surgical procedures
and thus the prescribing of fentanyl for post-operative pain was contraindicated. In addition, if MSG Kinamon had been taking
opioids prior to the fentanyl prescription, he would have been opioid tolerant and the level of fentanyl occurring approximately
12 hours after application would not have been fatal. MSG Kinamon's immediate fatal respiratory depression clearly indicates
that there could not have been any demonstration of opioid tolerance, in which case Duragesic® would have been contraindicated.
This should be plenty of information to invoke disciplinary action against Dr. Tibesar
- it isn't a complicated case.
Neither MSG Kinamon, nor the manufacturer, nor an adverse
reaction to the prescription is to blame; MSG Kinamon's death was 100% physician error. As you know, poisoning is defined
as drugs given in error (wrong drug) or medication given in error (wrong dose, wrong patient, wrong route
of administration). In an adverse reaction, the patient experienced a reaction even though it was the correct patient, drug,
dose, and route of administration. In a poisoning, something was done wrong. Furthermore, prescribing a second narcotic (oxycodone)
which depresses respiration in addition to the fentanyl was clearly contraindicated as well. Overall, Dr. Tibesar prescribed contraindicated fentanyl at 6 times the recommended initial dose for an opioid tolerant
patient, as well as oxycodone which is contraindicated for being taken with fentanyl.
far no one has been able to justify the recklessness of Dr. Tibesar. If the Board will not accept responsibility for disciplining Dr. Tibesar then the Board clearly isn't fulfilling its mission of protecting the public from incompetence.
When a Minnesota licensed physician needlessly ends a patient's life because he did
not adhere to the standards of care, the Board should be more concerned that the incident occurred, NOT the location of the
incident. The obvious recklessness of Dr. Tibesar's actions should be of great
concern to the Board.
The letter was sent to the following:
Mr. Glenn A. Fine, United States Inspector General
United States Senator Coleman
United States Senator Klobuchar
Governor Pawlenty of Minnesota
Mr. John Kline, United States House of Representatives
Attorney General Swanson
Minnesota Senator Marty
Minnesota Senator Gerlach
Ms. Shelley Madore, Minnesota House of Representatives
Dr. James N. Thompson,
President/CEO, Federation of State Medical Boards
Dr. Samantha Collier, Chief Medical Officer,
Rick Marinelli, President, American Academy of Pain Medicine
Cynthia Porter, Senior Manager, American Pain Society