Problem The introduction of sugammadex at a rural hospital in Maryland led to a noticeable rise in the expense to pharmacologically reverse neuromuscular blockade. As sugammadex was used in more than half of the cases involving rocuronium administration (52%), the Anesthesia Department was urged to explore cost-saving measures. Purpose The purpose of this quality improvement project was to develop and implement an evidence-based cognitive aid to assist anesthesia providers in selecting reversal agents for neuromuscular blockade, while decreasing cost and improving patient outcomes. Methods A cognitive aid on neuromuscular blockade reversal was tailored to the needs of the institution. Using either qualitative or quantitative measures of blockade depth, reversal agent and dose were recommended. The cognitive aid was placed within each operating room (n=10). Data collection was performed using staff surveys, in addition to weekly anesthesia records and monthly pharmaceutical reports. Run chart analysis was performed. The primary outcome was compliance to the cognitive aid self-reported by anesthesia providers (n=23) and through review of anesthetic records (n=884). Secondary outcomes included the number of anesthesia providers educated (n=53) and total number of sugammadex administrations. Results The pre-implementation monthly average of sugammadex administrations was 330. In-person education was received by 22 anesthesia providers (42%). Baseline data from anesthesia records showed 57 of 104 cases were compliant to the cognitive aid (M=55.4%). Following implementation, preliminary reported compliance by anesthesia providers was 100%. Anesthesia records showed lower compliance, with 483 of 774 cases following recommendations (M=62.4%). While these records showed lower than reported compliance, there was overall increased compliance following implementation. The average number of sugammadex administrations increased, with a post-implementation average of 355per month. Conclusions Findings suggest using a cognitive aid to guide the selection of reversal agents was associated with improved decision-making regarding the appropriate reversal agent without compromising patient safety. However, monthly sugammadex administrations were increased. The institution should continue to explore strategies for cost-effective neuromuscular blockade reversal while considering cognitive aid compliance, patient safety and financial implications.