The presentation provides with a description of train-of-four monitoring, train-of-four ratios (TOFR), and the current ‘gold standard’ for safe neuromuscular blockade recovery. Residual neuromuscular blockade is described with relation to train-of-four ratio, clinical signs and symptoms, and adverse patient outcomes. Current neuromuscular blockade monitoring practices are defined. This includes both traditional clinical tests and qualitative neuromuscular blockade monitoring devices. A summary of the current practice guidelines as defined by both the American Association of Nurse Anesthetists (AANA) and the American Society of Anesthesiologists (ASA) is discussed. There is a review of current research evidence regarding the routine practices of anesthesia providers and the inherent variability and limitations of qualitative devices. Next, we delve into the types of quantitative neuromuscular blockade monitors including a description of monitoring methods, strengths and weaknesses, and how these devices can be incorporated into practice to positively affect patient outcomes. Finally, there is a review of the recommendations published by an international panel of experts on neuromuscular blockade monitoring.