A hold was indicated for both prescriptions for drug interaction. The doctor overrode the warnings with the following comments, "used in combo." The overrides were not further explained. A pharmacist and board certified pharmacotherapy specialist at Wright-Patterson Air Force Base confirmed that MSG Kinamon was prescribed Roxicet in combination with Duragesic (fentanyl transdermal patch) and explained Roxicet and Duragesic were both considered central nervous system (CNS) depressants. Patients were not typically monitored for initial administration of fentanyl transdermal patches, but the pharmacist confirmed the combined therapy of multiple CNS depressants increased the risk of respiratory depression and monitoring the patient during initial dosage administration was advisable. The pharmacist described the doctor's fentanyl dosage of 75 mcg/h as high for MSG Kinamon.  The pharmacist stated initial dosages typically started at 25 mcg/h. Additionally, the pharmacist did not consider MSG Kinamon to be opioid tolerant. The U.S. Food and Drug Administration (FDA) issued an advisory in July 2005, in which they highlighted the fentanyl patches should not be used to treat pain after an operation and should only be used on opioid tolerant patients. A review of full prescribing information for Duragesic (fentanyl transdermal system) revealed Duragesic is prescribed for management of persistent, chronic pain and is not recommended in the management of post-operative pain. Duragesic should only be used in patients who are already receiving opioid (narcotic pain killer) therapy and have demonstrated opioid tolerance; use in non-opioid tolerant patients may lead to fatal respiratory depression. Overestimating the dose can result in fatal overdose with the first dose. Use of Duragesic should be monitored during the initial 24-72 hours when serum concentrations peak from the initial patch. (emphasis added)

Per the report, the matter being investigated was "negligent homicide." Even though there were numerous references to the inappropriate prescribing of the Duragesic and Roxicet, no action was taken against Dr. Tibesar.

In summary, Dr. Tibesar was not charged with negligent homicide under the Uniform Code of Military Justice, can not be criminally charged by the State of Ohio unless the military requests that state and local authorities be involved in the case, can not be sued in civil court because of the Feres doctrine, and has not been disciplined by his state licensing board.