Abstract: Objective: To check out the function of Root Cause Analysis in analyzing the pathological specimen delivery errors in operating room. Methods: An RCA team was set up to analyze the proximate cause and the ultimate cause of error by using the method of RCA, and then the improved measures were proposed and carried out. Results: Before using the method of RCA, the average error rate was 1.03%. After using RCA, the average error rate dropped to 0.26%; Nurse had a positive selfassessment.Conclusion: RCA is a scientific method in the management of pathological specimen delivery flow. RCA method can not only improve the comprehensive ability of nurses ,but also can realize the goal of patient safety in operation room.