A hospital has apologised for asking elderly patients to attract nurses' attention with a tambourine.
Patients had to use the instrument in Cardiff Royal Infirmary's West Wing day room where there is no alarm system.
Wales' older people's commissioner Ruth Marks said it did "not afford any patient dignity and respect, let alone safety".
Health officials admitted it was inappropriate and said a bell will be used.
Ms Marks said a system where patients could easily call for help was needed.
"Whatever system is in place, it is vital that these areas are checked regularly by staff. If there was an emergency, there may be no opportunity to call for help."
"Resources may be limited, but installing a system so people can easily call for help whilst in hospital must be a priority."
Steve Allen, chief officer of Cardiff and Vale of Glamorgan Community Health Council, also called the tambourine "totally inappropriate and totally unacceptable."
"Patients should never have to use a tambourine. I also understand anecdotally that maracas were used which was unacceptable," he said.
One relative of a patient said the use of the tambourine was "ridiculous".
"These people are pensioners, not members of The Monkees or Mick Jagger.
"Where is the dignity in asking old and frail people to bash on a tambourine if they are in trouble? It makes the NHS look like a laughing stock," he said.
Another relative said was shocked when his 90-year-old mother told him about the tambourine alarm.
"I thought she was joking about the tambourine but I went to the day room and there it was. I even took a photograph of it to prove it," he said.
"I gave the tambourine a good hard shaking - but after 16 minutes I gave up as no-one responded."
Charity Age Cymru said dignity and respect should be at the heart of care.
'Not optional extras'
"Expecting patients to use a tambourine to attract attention is inappropriate, patronising and it denies them the dignity we all deserve," said Victoria Lloyd, the charity's director of influencing and programme development.
"Dignity and respect are not optional extras - they must be at the heart of care and health services for older people because they are a vital part of their treatment and rehabilitation."
Ruth Walker, executive director of nursing at Cardiff and Vale University Health Board, said they took action as soon as the matter was brought to their attention.
"It appears that well-meaning staff have looked for ways to allow patients to make better use of the day room as part of their recovery and provide a way of calling for help when physio or other staff are not nearby.
She said a hand bell had previously been provided but was too heavy and cumbersome for frailer patients and staff looked for an alternative.
"Sadly the solution, while well intentioned, was not appropriate," she said.
"A lightweight hand bell will now be sourced as a matter of urgency and patients will be accompanied while using the day room in the meantime.
"The care and dignity of all our patients is vitally important to everyone at the health board and we sincerely apologise for any distress this has caused and are happy to meet with the family in question to discuss their concerns.