Background <p>Pesticides are extensively employed across agricultural, public health, and industrial sectors, yielding significant benefits in crop protection and food security. However, their overuse and misuse have escalated pesticide poisoning into a pressing global public health issue—particularly in developing countries such as China. As the world’s largest pesticide consumer, China continues to experience a disproportionately high burden of pesticide-related morbidity and mortality, even following the nationwide phase-out of highly hazardous compounds. Alarmingly, intentional ingestion of pesticides remains the most common method of suicide in the country. Shandong Province—the leading agricultural producer in China—offers a strategically relevant setting for epidemiological investigation. Within it, Zibo City stands out as a representative case: it integrates both traditional and modern farming systems and operates a well-established, comprehensive surveillance system for pesticide poisoning, thereby providing robust empirical grounding for analyzing the distribution, determinants, and trends of pesticide poisoning.</p> Methods <p>A retrospective epidemiological study was conducted on pesticide poisoning cases reported in Zibo City between 2014 and 2023. Case data were extracted from the Occupational Disease and Health Hazard Factors Monitoring Information System—a nationally standardized subsystem of China’s Integrated Disease Prevention and Control Information System—while population denominators were obtained from the official Zibo Statistical Yearbooks (2014–2023 editions). A structured case database was developed in Microsoft Excel, and all statistical analyses were performed using R 4.5.2 Categorical variables were compared using chi-square tests (or Fisher’s exact test where expected cell counts were &lt; 5), and binary logistic regression was employed to identify independent predictors of in-hospital mortality; results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI), with statistical significance set at <i>P</i> &lt; 0.05. Case definitions encompassed demographic characteristics, exposure circumstances, pesticide classification (e.g., organophosphates, carbamates), clinical severity, treatment outcomes, and occupational attribution—specifically distinguishing between occupational and non-occupational poisoning.</p> Results <p>A total of 762 pesticide poisoning cases were identified between 2014 and 2023 in Zibo City, including 400 males (52.5%) and 133 fatalities, yielding an overall case fatality rate (CFR) of 17.6%. The mean age of cases was 55.10 ± 20.04 years, with an average annual incidence of 1.63 per 100,000 population. The 65-75-year age group accounted for the largest proportion of cases (20.5%), and CFR increased monotonically with advancing age. Females exhibited a significantly higher CFR (18.8%) than males (16.5%). Non-occupational intentional ingestion—predominantly self-poisoning—constituted the leading exposure mechanism (68.9% of all cases) and carried the highest CFR (23.6%), whereas no fatalities were observed among occupationally exposed individuals (CFR = 0%). Among pesticide classes, herbicides demonstrated the highest CFR (48.3%), followed by insecticides (14.6%); organophosphorus compounds represented 84.3% of all insecticide-related poisonings, with dichlorvos being the most frequently implicated active ingredient. Temporally, the annual incidence of pesticide poisoning rose steadily over the study decade, peaking in 2023 (<i>n</i> = 147) and reaching its nadir in 2015 (<i>n</i> = 30), while the CFR declined progressively. Seasonally, cases were concentrated between March and October: occupational and intentional poisonings peaked during June–August, whereas accidental poisonings clustered in April–September. Geographically, Linzi, Zichuan, and Gaoqing Districts reported the highest case counts; conversely, Huantai, Yiyuan, and Boshan Districts recorded elevated CFRs. Multivariable binary logistic regression identified four independent predictors of in-hospital mortality: age ≥ 45 years (with CFR risk increasing incrementally with age), female sex (aOR = 1.69, 95% CI: 1.08–2.72), herbicide exposure (aOR = 1.79, 95% CI: 1.16–2.80), and non-occupational intentional ingestion (aOR = 2.71, 95% CI: 1.31–6.37). Comparative analysis with the preceding 2006–2013 period revealed a declining trend in the proportion of organophosphorus pesticide poisonings and a concurrent rise in herbicide-related incidents.</p> Conclusions <p>Zibo’s pesticide poisoning features a notably higher CFR than other Chinese regions, with rising incidence yet falling CFR reflecting partial treatment success and unoptimized prevention, and non-occupational intentional ingestion stands as the core issue for local control. Age, gender, pesticide type and poisoning cause are key mortality factors, and the poisoning presents distinct demographic and geographical distribution characteristics driven by rural aging, social pressure and regional medical-economic gaps, for which targeted prevention and control strategies are proposed accordingly. This study has certain limitations in data sources and research scope, so future research needs to improve data collection and expand research coverage to offer more scientific support for relevant policies.</p> Trial registration <p>Clinical trial number: Not applicable. This is a retrospective observational epidemiological study without any health-related interventions assigned to participants, which does not meet the WHO/ICMJE definition of a clinical trial, so trial registration is not required.</p>